Nokea
A school-aged child who was diagnosed two weeks ago with hepatitis A.
Which of the following responses by the nurse is BEST?
- A. You must isolate your child at home for two more weeks.
- B. Why don't you speak with the physician about this matter?
- C. Your child may return to school this week.
- D. Your child may return to school in 2 weeks but cannot participate in sports.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) communicable for 2-3 weeks before onset of jaundice and about 1 week after onset of jaundice (2) passing the buck (3) correct-type A hepatitis is not infectious within a week or so after the onset of jaundice, child can return to school (4) can return to school, activity at that time depends on the child's energy level
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The nurse is caring for a client who was in a motor vehicle accident. His blood pressure is dropping rapidly. What should the nurse observe the client for before placing the client in shock position?
- A. Long bone fractures
- B. Air embolus
- C. Head injury
- D. Thrombophlebitis
Correct Answer: C
Rationale: Shock position (legs elevated) is contraindicated in head injury due to increased intracranial pressure risk. Observing for head injury ensures safety before positioning.
A postoperative client has returned to his room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused.
Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call bell within the client's reach.
- B. Stay with the client until he is totally oriented.
- C. Restrain all four extremities until the client is oriented.
- D. Elevate the side rails until the client is fully awake.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not the safety action (2) unnecessary to stay with the client, especially while he is sleeping (3) restraints are unnecessary at this time (4) correct-side rails should always be elevated for any disoriented client
Digoxin has been prescribed for a 70-year-old man who has atrial fibrillation. Which behavior indicates that the client understands the nurse's instructions about taking digoxin?
- A. The client states that he will not spend much time in the sun.
- B. The client says to the nurse, 'Is this the correct way to check my pulse? I want to do it right.'
- C. The client tells the nurse he will be very careful to sit on the edge of the bed for a few moments before standing up.
- D. The client says, 'I will not take Cialis while I am taking this medicine.'
Correct Answer: B
Rationale: Checking pulse before taking digoxin prevents administration if bradycardia is present, indicating understanding of toxicity monitoring.
The nurse is reviewing procedures with the health care team. The nurse should intervene if an RN staff member makes which of the following statements?
- A. It is my responsibility to ensure that the consent form has been signed and is attached to the patient's chart.'
- B. It is my responsibility to witness the signature of the patient before surgery is performed.'
- C. It is my responsibility to explain the surgery and ask the patient to sign the consent form.'
- D. It is my responsibility to answer questions that the patient may have before surgery.'
Correct Answer: C
Rationale: physician should provide explanation and obtain patient's signature
A baby is delivered following a pregnancy complicated by gestational diabetes. What should the nurse observe the baby for?
- A. Infection
- B. Hyperglycemia
- C. Acidosis
- D. Hypoglycemia
Correct Answer: D
Rationale: Infants of mothers with gestational diabetes are at risk for hypoglycemia due to high fetal insulin levels from maternal hyperglycemia, requiring close monitoring.