Nokea
Which of the following conditions in the child's medical history should the nurse identify as a contraindication to the procedure?
- A. Hypertension
- B. Primary glaucoma
- C. History of appendectomy
- D. Iron deficiency anemia
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to certain procedures due to the risk of complications such as increased bleeding or cardiovascular events. Primary glaucoma, history of appendectomy, and iron deficiency anemia are not contraindications for the procedure mentioned. Glaucoma and appendectomy are unrelated to the procedure, while iron deficiency anemia may not directly impact the safety of the procedure.
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Which of the following food choices is appropriate for this client?
- A. Canned barley soup
- B. Potato pancakes.
- C. Wheat crackers
- D. White flour tortillas
Correct Answer: B
Rationale: The correct answer is B: Potato pancakes. This choice is appropriate as it is likely to be well-tolerated by the client. Potatoes are a good source of carbohydrates and can provide energy. Additionally, potato pancakes are easy to digest and can be a good option for someone with digestive issues. On the other hand, A, C, and D contain grains that may be harder to digest for some individuals, especially if they have digestive concerns. Canned barley soup (A) may also contain added preservatives and sodium, which may not be ideal for the client's condition. Wheat crackers (C) can be high in fiber and may be difficult to digest. White flour tortillas (D) are made from refined grains and may not provide the necessary nutrients for the client.
A nurse is assessing a client who received hydromorphone 4mg IV 15 min ago. The client has a respiratory rate of 10/min. the nurse should prepare to administer which of the following medications?
- A. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Atropine
- E. Diphenhydramine
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Hydromorphone is an opioid that can cause respiratory depression. The client's low respiratory rate of 10/min indicates potential opioid overdose. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression. Administering naloxone can help restore normal breathing in the client. Flumazenil (B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (C) is used for toxin ingestion, not opioid overdose. Atropine (D) is a medication used for bradycardia, not respiratory depression. Diphenhydramine (E) is an antihistamine and is not indicated in this situation.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I will receive a limited amount of pain medication when I press the button.
- B. I should have my family press the button for me when I am asleep.
- C. I can receive as much pain medication as I need by pressing the button.
- D. I should wait until my pain is severe before using the PCA pump.
Correct Answer: A
Rationale: The correct answer is A because it shows the client understands the concept of patient-controlled analgesia (PCA) pump, where they will receive a limited amount of pain medication when they press the button. This indicates the client knows they have control over their pain relief.
Choice B is incorrect as having someone else press the button goes against the purpose of PCA, which is for the patient to self-administer medication. Choice C is incorrect because unlimited medication can lead to overdose. Choice D is incorrect as waiting for severe pain can lead to ineffective pain management.
A nurse is preparing to admit a six-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room (airborne)
- B. Place the child in a semi-private room with another child who has varicella
- C. Require the child to wear a surgical mask at all times
- D. Ensure the child's visitors wear droplet precautions
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room (airborne). This is because varicella (chickenpox) is transmitted through airborne droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others.
B: Placing the child in a semi-private room with another child who has varicella increases the risk of spreading the infection to each other.
C: Requiring the child to wear a surgical mask at all times may help reduce the spread of droplets, but it does not address the airborne transmission of varicella effectively.
D: Ensuring the child's visitors wear droplet precautions is not sufficient to prevent airborne transmission within the unit.
Which of the following sites should the nurse use?
- A. Axillary
- B. Rectal
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The nurse should use the rectal site for temperature measurement as it provides the most accurate core body temperature reading. Rectal temperature closely reflects internal body temperature, making it the preferred site for assessing critically ill patients or infants who cannot cooperate for oral measurements. Axillary, oral, and tympanic sites may not accurately represent core body temperature due to external factors affecting the readings. Rectal temperature is the gold standard for accurate temperature measurement in certain clinical situations.