Nokea
Which of the following findings should indicate to the nurse that treatment has been effective?
- A. Odorless urine
- B. No report of pain with voiding
- C. Urine output 256 mL over 8 hours
- D. Temperature 37.2° C (99° F)
Correct Answer: C
Rationale: The correct answer is C: Urine output 256 mL over 8 hours. This finding indicates effective treatment as it shows adequate kidney function and hydration status. Normal urine output is 30-50 mL/hr, so 256 mL over 8 hours is within the expected range.
A: Odorless urine is a general indicator of hydration but not a definitive sign of treatment effectiveness.
B: No report of pain with voiding is subjective and may not always reflect treatment effectiveness.
D: Temperature within normal range is a good sign, but it does not directly indicate treatment effectiveness related to the urinary system.
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For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.
Complete the following sentence by using the list of options. The nurse should first----- followed by -------
- A. Teach the child's parents the importance of inspecting the child's play area.
- B. Obtain informed consent.
- C. Monitor the child closely for return of gag reflex.
- D. Encourage the parents to inspect toys for easily removable parts.
- E. keep the child NPO
- F. prepare the child for flexible endoscopy
Correct Answer: E,F
Rationale: The correct answer is E, F. Firstly, keeping the child NPO (nothing by mouth) is essential before a flexible endoscopy to prevent aspiration during the procedure. Secondly, preparing the child for the flexible endoscopy involves informing them about the procedure and ensuring they are physically and emotionally ready. Choice A is incorrect as it does not directly relate to the procedure; B is not the immediate priority before the endoscopy; C is important post-procedure, not first; D is relevant but not the initial step.
Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will ensure that my child consumes a high-calorie diet.
- B. I will expect my child to need annual sweat chloride testing.
- C. I will have my child chew the pancrelipase medication before eating.
- D. I will administer dormase alfa every 4 hours for wheezing.
Correct Answer: A
Rationale: The correct answer is A because ensuring the child consumes a high-calorie diet demonstrates an understanding of the teaching regarding managing cystic fibrosis, a condition that requires a high-calorie intake to maintain weight and overall health. This statement aligns with the need for nutritional support in cystic fibrosis management.
Choice B is incorrect because annual sweat chloride testing is not related to dietary management. Choice C is incorrect as chewing pancrelipase medication before eating is not necessary for understanding the teaching about cystic fibrosis. Choice D is incorrect as administering dormase alfa every 4 hours for wheezing does not pertain to dietary requirements in cystic fibrosis.
Which of the following instructions should the nurse include in the teaching?
- A. Apply bactericidal ointment to lesions.
- B. Administer acyclovir PO two times per day.
- C. Soak hairbrushes in boiling water for 10 min.
- D. Seal soft toys in a plastic bag for 14 days.
Correct Answer: A
Rationale: The correct answer is A: Apply bactericidal ointment to lesions. This instruction is essential to prevent secondary bacterial infection in lesions caused by herpes zoster. The ointment will help to keep the lesions clean and prevent bacterial growth. Administering acyclovir helps treat the viral infection but does not prevent bacterial infection. Soaking hairbrushes and sealing soft toys are not directly related to preventing infection in the lesions. Overall, the focus should be on proper wound care to prevent complications.
Which of the following statements should the nurse make?
- A. You need to come back in a week for retesting.
- B. I have to notify the public health department.
- C. I have to contact your parents.
- D. Let's review the side effects of metronidazole.
Correct Answer: B
Rationale: The correct answer is B: I have to notify the public health department. This statement is crucial in cases of reportable diseases to prevent the spread of infection. Notifying the public health department is a legal and ethical responsibility to ensure appropriate measures are taken. Choice A is incorrect because it lacks urgency in notifying the proper authorities. Choice C is incorrect as contacting the patient's parents may not be necessary in this situation. Choice D is incorrect as reviewing side effects of metronidazole is not the priority when dealing with a reportable disease.