Nokea
Which laboratory result would be expected during the emergent phase of a burn injury?
- A. Glucose 100 mg/dl
- B. Potassium 3.5 mEq/l
- C. Sodium 142 mEq/l
- D. Albumin 4.2 gm/dl
Correct Answer: A
Rationale: Glucose levels rise as a result of the stress response during the emergent phase. Answers B, C, and D are within normal range. K+ and Na+ would be elevated, whereas albumin would be lowered during the emergent period due to increased permeability.
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A mother brings her 17-month-old son to the well-baby clinic for a routine check-up. She confides to the nurse that she is concerned because her son sucks his thumb, especially at night when he is put to bed.
Which of the suggestions by the nurse would be BEST?
- A. If you want the behavior to stop put a negative reinforcer, such as red pepper, on this thumb.'
- B. Don't intervene at this time. This behavior usually subsides after 24 months of age.'
- C. What you are seeing is a common form of self-stimulation. You should discourage this behavior.'
- D. This behavior will cause malformation of his teeth. You should wrap his thumb at bedtime.'
Correct Answer: B
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember growth and development concepts. (1) controversial treatment for an older child (2) correct-normal behavior, peaks at 18-20 months, most prevalent when child is hungry or tired (3) normal behavior in child this age, should not be discouraged (4) malocclusion occurs if thumb sucking persists past 4 years old or when permanent teeth erupt
A client with angina is experiencing migraine headaches. The physician has prescribed sumatriptan succinate (Imitrex). Which nursing action is most appropriate?
- A. Consult with the RN before administration.
- B. Try to obtain samples for the client to take home.
- C. Perform discharge teaching regarding this drug.
- D. Consult social services for financial assistance with obtaining the drug.
Correct Answer: A
Rationale: Sumatriptan is contraindicated in clients with angina due to its vasoconstrictive effects, which could exacerbate cardiac ischemia. Consulting the RN to verify the order is the most appropriate action. Obtaining samples, discharge teaching, or consulting social services do not address the safety concern, so answers B, C, and D are incorrect.
The nurse is caring for a client who had a total gastrectomy performed this morning. When the client returns to the nursing care unit, the drainage from the nasogastric tube is red. What is the nurse's best response to this?
- A. Report it immediately to the charge nurse or the physician
- B. Record the finding and continue to observe
- C. Immediately apply pressure to the operative site
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Red nasogastric drainage post-gastrectomy suggests bleeding, requiring immediate reporting to assess for hemorrhage.
The nurse is developing a meal plan that would provide the maximum possible amount of iron for a child with anemia. Which dinner menu would be best?
- A. Fish sticks, french fries, banana, cookies, milk
- B. Ground beef patty, lima beans, wheat roll, raisins, milk
- C. Chicken nuggets, macaroni, peas, cantaloupe, milk
- D. Peanut butter and jelly sandwich, apple slices, milk
Correct Answer: B
Rationale: Iron rich foods include red meat, fish, egg yolks, green leafy vegetables, legumes, whole grains, and dried fruits such as raisins. This dinner is the best choice. It is high in iron and is appropriate for a toddler.
A client is being treated for hypovolemia.
Which of the following observations should the nurse identify as the desired response to fluid replacement?
- A. Urine output 160 cc/8 h.
- B. Hgb 11 g, Hct 33%.
- C. Arterial pH 7.34.
- D. CVP reading of 8 cm of water pressure.
Correct Answer: D
Rationale: Strategy: Determine the significance of each answer choice and how it relates to hypovolemia. (1) indicates a hypovolemic state (2) indicates a hypovolemic state (3) indicates acidosis (4) correct-normal range for CVP is 3-8 cm water pressure (or 2-6 mm Hg); reading of 8 cm water pressure would indicate a desired response to fluid replacement