Nokea
An infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis.
Which of the following should be the nursing priority for an infant admitted to the pediatric unit with possible Haemophilus influenzae meningitis?
- A. Encourage intake of oral fluids to prevent dehydration.
- B. Restrain the child appropriately to maintain the integrity of the IV site.
- C. Place the child on droplet precautions.
- D. Encourage the parents to hold and rock the infant to promote comfort.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) fluid requirements are determined by child's hydration status; fluids are usually limited to prevent cerebral edema (2) not a priority (3) correct-to prevent spread of infection, child is placed on droplet precautions for at least 24 hours after implementation of antibiotic therapy (4) would cause discomfort to infant's head
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A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
- A. A cerebral vascular accident
- B. Postoperative meningitis
- C. Medication reaction
- D. Metabolic alkalosis
Correct Answer: A
Rationale: A cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, increasing the risk of thromboembolic events like cerebrovascular accidents, which can manifest as seizures.
A woman has returned from surgery after a right mastectomy with an IV of 0.9% NaCl infusing at 100 cc/hour into her left forearm. Several hours later, the IV infiltrates. The nurse is supervising a student nurse preparing to insert a new peripheral intravenous catheter. The nurse would intervene in which of the following situations?
- A. The student nurse selects a site where the veins are soft and elastic.
- B. The student nurse selects a site on the distal portion of the left arm.
- C. The student nurse selects a site close to the joint to provide for stability.
- D. The student nurse holds the skin taut to stabilize the vein.
Correct Answer: C
Rationale: inappropriate; movement in area could cause displacement
A comatose patient who is incontinent.
The nurse should intervene if which of the following actions is noted?
- A. The nurse assistant answers the phone while wearing gloves.
- B. The nursing assistant log rolls the patient to provide back care.
- C. The nursing assistant places an incontinence pad under the patient.
- D. The nursing assistant positions the patient on the left side, head elevated.
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a rash to my doctor.
- B. I should take this medication at the same time each day.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my seizures stop.
Correct Answer: D
Rationale: Stopping lamotrigine when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: rash may indicate Stevens-Johnson syndrome, consistent timing ensures steady levels, and alcohol increases sedation.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.