Nokea
Which of the following is NOT an essential component of a restraint order?
- A. Informed consent for the restraint
- B. The reason for the restraint
- C. The type of restraint to be used
- D. Client behaviors that necessitated the restraints
Correct Answer: A
Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.
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Which of the following is appropriate when developing a plan of care for promoting the development of a preschooler? Select all that apply.
- A. Providing anticipatory guidance for parents.
- B. Helping the parents understand their child's behavior.
- C. Identifying deviations from normal growth and development patterns.
- D. Determining the child's future development.
- E. Sending the child to a day care center.
Correct Answer: A,B,C
Rationale: Anticipatory guidance, understanding behavior, and identifying deviations support preschooler development. Predicting future development is not feasible, and daycare is not universally required.
Which of the following conditions is a potential consequence of a prolonged QT interval?
- A. Serious electrolyte imbalance.
- B. Ventricular dysrhythmias.
- C. Heart block.
- D. Atrial dysrhythmias.
Correct Answer: B
Rationale: A prolonged QT interval increases the risk of ventricular dysrhythmias, such as torsades de pointes, which can be life-threatening.
An I.V. infusion is to be administered through a scalp vein on an infant's head. What should the nurse tell the parents to prepare them for the procedure?
- A. It may be necessary to remove a small amount of hair from the infant's scalp.
- B. A sedative will be given to help keep the infant quiet.
- C. Administering the infant will be delayed until the infusion has been completed.
- D. Holding the infant will be contraindicated while the infusion is being administered.
Correct Answer: A
Rationale: Removing a small amount of hair may be necessary to secure the I.V. site on the scalp.
The nurse is reviewing the serum laboratory test results for a client with a diagnosis of sickle cell anemia. Which parameter should the nurse anticipate will be elevated?
- A. Sodium
- B. Hemoglobin-S
- C. Hemoglobin A1c
- D. Prothrombin time
Correct Answer: B
Rationale: Sickle cell anemia is a severe anemia that affects African Americans predominantly and is characterized by sickled hemoglobin, or HgbS. The client must have two abnormal genes yielding hemoglobin-S to have sickle cell anemia. A client could have sickle cell trait by carrying one hemoglobin-A gene and one hemoglobin-S gene; then, the client has a less severe form of sickle cell anemia. The remaining options are unrelated to sickle cell anemia.
The best way to determine whether or not a medication is compatible with a particular intravenous fluid is to:
- A. Mix a small amount of the medication in a small amount of the intravenous fluid and then examine this mixture for color changes
- B. Refer to a compatibility chart
- C. Call the doctor and ask if the medication is compatible with the particular intravenous fluid
- D. Mix a small amount of the medication in a small amount of the intravenous fluid and then examine this mixture for any precipitates
Correct Answer: B
Rationale: A compatibility chart provides standardized, evidence-based information on medication and IV fluid compatibility, ensuring safety.