Nokea
An infant is admitted for vomiting and diarrhea. The infant's anterior fontanelle is depressed, and he has a fever of 103.2°F (39.5°C).
Which of the following nursing actions would be MOST appropriate?
- A. Determine daily weights and evaluate weight loss.
- B. Evaluate infant's ability to take in fluids.
- C. Place a full bottle of Pedi-Lyte at the bedside.
- D. Start an intravenous infusion.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) assessment, correct information, but is not what the question asks for (2) correct-assessment, will assist in determining if hydration can be done through oral fluids alone (3) implementation, does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee that the infant is taking fluids (4) implementation, would be implemented later
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A man is presently employed as a night watchman. When he comes to the clinic for a visit, he tells the nurse he is having difficulty sleeping and is fatigued much of the time.
Which of the following responses by the nurse is BEST?
- A. Tell me about your usual sleeping habits.'
- B. You probably sleep when you can during your night tour.'
- C. This is normal for your age group.'
- D. Working the night shift is known to disrupt sleep patterns.'
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assessment, open-ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) closed communication, generalization
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- A. High Fowler's
- B. Supine
- C. Left lateral
- D. Low Fowler's
Correct Answer: A
Rationale: High Fowler's. This position decreases cardiac workload and facilitates breathing.
The nurse is caring for a client in a manic phase of bipolar affective disorder. It is MOST important for the nurse to offer which of the following meals?
- A. Tuna salad sandwich and orange slices.
- B. Bologna sandwich and french fries.
- C. Milkshake and banana.
- D. Fried chicken and tossed salad.
Correct Answer: A
Rationale: Manic clients need portable, nutritious finger foods due to high energy and distractibility. Tuna salad sandwich and orange slices provide balanced nutrition. Options B, C, and D are less suitable: bologna is processed, milkshakes lack variety, and fried chicken is messy.
A home care nurse is planning activities for the day. Which of the following clients should the nurse see FIRST?
- A. A new mother is breastfeeding her two-day-old infant who was born five days early.
- B. A man discharged yesterday following treatment with IV heparin for a deep vein thrombosis.
- C. An elderly woman discharged from the hospital three days ago with pneumonia.
- D. An elderly man who used all his diuretic medication and is expectorating pink-tinged mucus.
Correct Answer: D
Rationale: symptoms of pulmonary edema; requires immediate attention
A 35-year-old woman receiving metronidazole (Flagyl) 250 mg PO tid for 7 days.
Which of the following statements, if made by the woman, would indicate that teaching has been effective?
- A. I should take this medication between meals to increase absorption.'
- B. I shouldn't drink alcohol while I am taking this medication.'
- C. If I experience a metallic taste in my mouth while taking this mediation, I should notify the physician.'
- D. I should avoid strong sunlight while I am taking this medication.'
Correct Answer: B
Rationale: Strategy: 'Teaching has been effective' indicates a correct statement. (1) given with meals to decrease GI upset (2) correct-causes Antabuse-like reaction of nausea and vomiting, headache, cramps, flushing (3) frequently seen, not a problem (4) sensitivity to sun not seen with this medication