Nokea
Which diagnosis for the client with tuberculosis would have the greatest impact on public health?
- A. Ineffective breathing pattern
- B. Deficient knowledge
- C. Fatigue
- D. Ineffective family therapeutic regimen management
Correct Answer: B
Rationale: Deficient knowledge about TB transmission risks public health by increasing spread, requiring education to ensure compliance with treatment and precautions.
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The nurse is caring for an adult who is taking digoxin (Lanoxin) 0.25 mg daily. Which comment by the client is of greatest concern to the nurse because the client is taking digoxin?
- A. I don't seem to have much of an appetite lately.'
- B. My energy level is not as high as it once was.'
- C. My pulse yesterday was 60.'
- D. I have a pain in my right foot.'
Correct Answer: C
Rationale: A pulse of 60 may indicate bradycardia, a potential sign of digoxin toxicity, requiring immediate assessment. Anorexia and fatigue are less specific, and foot pain is unrelated to digoxin.
Following a CT scan with contrast medium, the nurse should give attention to:
- A. Maintaining bed rest for 8 hours
- B. Forcing fluids
- C. Observing the puncture site for hemorrhage
- D. Administering pain medication
Correct Answer: B
Rationale: Forcing fluids promotes excretion of contrast medium, reducing risk of renal toxicity. Bed rest and hemorrhage monitoring are not typically required.
A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is
- A. call for emergency transport to the hospital
- B. immobilize the limb and joints above and below the injury
- C. assess the child and the extent of the injury
- D. apply cold compresses to the injured area
Correct Answer: C
Rationale: When applying the nursing process, assessment is the first step in providing care. The '5 Ps' of vascular impairment can be used as a guide (pain, pulse, pallor, paresthesia, paralysis).
A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability.
Which of the following nursing actions is MOST appropriate?
- A. Decrease external stimuli in the child's room.
- B. Administer an analgesic as ordered.
- C. Notify and advise the physician of the child's status.
- D. Document the assessments and continue to observe.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may help the client to cope with current symptoms, but is not highest priority (2) will mask the signs of toxicity (3) correct-signs of toxicity need to be reported to the physician (4) does not take action to resolve the problem
A client has severe second- and third-degree burns over 75% of his body.
The nurse would be MOST concerned if which of the following was observed?
- A. Epigastric pain.
- B. Restlessness.
- C. Tachypnea.
- D. Lethargy.
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain