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Which action by the nursing student, caring for a child who sustained a head injury from a fall, indicates a need for further teaching?
- A. Forcing fluids
- B. Performing neurological assessments
- C. Keeping the child in a sitting-up position
- D. Keeping the child awake as much as possible
Correct Answer: A
Rationale: A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause fluid overload and increased ICP. Additionally, the nurse should not 'force' the client to do something. Neurological assessments must be performed to monitor for increased ICP. Sitting up will decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist in accurate evaluation of any cerebral edema that is present and will detect early coma.
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A client with chronic renal failure is receiving epoetin alfa (Epogen). The nurse should monitor the client for which of the following adverse effects?
- A. Hypertension.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypokalemia.
Correct Answer: A
Rationale: Epoetin alfa can cause hypertension due to increased red blood cell production and blood viscosity, requiring close monitoring.
A 7-year-old child with type 1 diabetes is admitted with diabetic ketoacidosis. Which intervention should the nurse prioritize?
- A. Administer insulin infusion
- B. Provide oral glucose
- C. Increase dietary carbohydrates
- D. Administer sodium bicarbonate
Correct Answer: A
Rationale: Insulin infusion is the priority in diabetic ketoacidosis to halt ketogenesis and correct hyperglycemia, addressing the underlying metabolic crisis.
A client has an anaphylactic reaction to penicillin that results in respiratory distress. Which of the following medications should the nurse anticipate administering?
- A. Dopamine (Intropin).
- B. Epinephrine.
- C. Albuterol (Proventil).
- D. Diphenhydramine (Benadryl).
Correct Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis, as it rapidly reverses respiratory distress and other symptoms by constricting blood vessels and relaxing airways.
You are the registered nurse in a multi ethnic community health department clinic. In this role you are asked to identify clients who have genetic risk factors related to ethnicity in order to screen them for some commonly occurring diseases and disorders. You would identify a client who is of:
- A. Mediterranean ethnicity for cystic fibrosis.
- B. African American ethnicity for Tay Sachs disease.
- C. British Isles ethnicity for psychiatric mental health disorders.
- D. Saudi Arabian ethnicity for sickle cell anemia.
Correct Answer: D
Rationale: Sickle cell anemia is strongly associated with populations from regions like Saudi Arabia, Africa, and parts of India. Screening clients of Saudi Arabian ethnicity for sickle cell anemia is appropriate due to the higher prevalence of the sickle cell trait in these populations.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.