Nokea
Which of the following pediatric clients is at greatest risk for latex allergy?
- A. The child with a myelomeningocele
- B. The child with epispadias
- C. The child with coxa plana
- D. The child with rheumatic fever
Correct Answer: A
Rationale: Children with myelomeningocele are at higher risk for latex allergy due to repeated exposure to latex products during medical procedures.
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The nurse is performing a neurological assessment on a client admitted with TIAs. Assessment findings reveal an absence of the gag reflex. The nurse suspects injury to:
- A. XII (hypoglossal)
- B. X (vagus)
- C. IX (glossopharyngeal)
- D. VII (facial)
Correct Answer: B
Rationale: The vagus nerve (X) innervates the pharynx and is responsible for the gag reflex, so its injury would cause an absent gag reflex.
The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection would let the nurse know that the teaching has been ineffective?
- A. Tuna casserole
- B. Ham salad sandwich
- C. Baked potato
- D. Broiled beef roast
Correct Answer: A
Rationale: Isoniazid can interact with tyramine-rich foods like tuna, causing adverse effects (e.g., hypertension). Selecting tuna casserole indicates ineffective teaching. The other foods are safe.
The nurse is caring for an elderly female client in an extended care facility who has dry age-related macular degeneration (AMD). Which nursing intervention would be the most appropriate?
- A. provide written materials to explain medications
- B. stand in front of the client when addressing her
- C. limit room lighting to create a relaxed environment
- D. encourage use of radio and CDs
Correct Answer: B
Rationale: Standing in front of the client maximizes her ability to see the nurse, as dry AMD affects central vision, making clear visual communication essential.
The nurse must administer 120 mg of amoxicillin oral suspension to a child. However, the only dosage available in the pharmacy is 200 mg per 5 mL. How many milliliters of suspension should the nurse administer? Record your answer using a whole number only.
Correct Answer: 3
Rationale: Dose = 120 mg, concentration = 200 mg/5 mL = 40 mg/mL. Volume = 120 m/40 mg/mL = 3 mL.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: Cushing's disease causes immunosuppression, increasing infection risk, warranting a private room.