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Which of the following statements should the nurse make?
- A. An alarm will sound if your child has an abnormal heart rhythm.
- B. Leads will be placed on your child's back prior to the procedure.
- C. This procedure will take at least 30 minutes to complete.
Correct Answer: B
Rationale: The correct answer is B because leads are typically placed on the back before a procedure like an electrocardiogram (ECG) to monitor the heart's electrical activity. This step is crucial for obtaining accurate results. Choice A is incorrect as alarms are not typically used during ECGs. Choice C is incorrect because the duration of the procedure can vary and is not necessarily 30 minutes. Choices D, E, F, and G are blank, so they do not provide any relevant information.
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Which of the following actions should the nurse take?
- A. Inform the client to contact the pharmacy regarding any questions related to the medication.
- B. Provide instructions to the client's parent with the client present.
- C. Instruct the client's parents to write down the information that is being provided.
- D. Ask how the client prefers to learn new information.
Correct Answer: D
Rationale: The correct answer is D: Ask how the client prefers to learn new information. This action is client-centered and promotes individualized care by understanding the client's preferred learning style. It helps tailor the teaching approach to best meet the client's needs, leading to improved understanding and compliance.
Choice A is incorrect because the nurse should provide medication information directly to the client instead of redirecting to the pharmacy.
Choice B is incorrect as it does not involve the client in the learning process, which is essential for effective education.
Choice C is incorrect as it focuses on the parents rather than the client, missing the opportunity to engage the client directly.
Overall, choice D stands out for its client-focused approach, making it the most appropriate action in this scenario.
The nurse should identify which of the following findings as a potential indicator of physical abuse?
- A. Front deciduous teeth missing
- B. Weight in 45th percentile
- C. Bruising around the wrists
- D. Abrasions on the knees
Correct Answer: C
Rationale: The correct answer is C, bruising around the wrists. This is indicative of physical abuse as it suggests grabbing or restraining. Front deciduous teeth missing (A) is more likely due to normal tooth loss. Weight in 45th percentile (B) is within a healthy range. Abrasions on the knees (D) are common in children.
For which of the following adverse effects should the nurse monitor?
- A. Hypotension
- B. Prolonged wound healing
- C. Stevens-Johnson syndrome
- D. Bradypnea
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. This is a severe adverse reaction characterized by blistering and peeling of the skin, mucous membranes involvement, and flu-like symptoms. It is potentially life-threatening and requires immediate medical intervention. The nurse should monitor for early signs such as rash, fever, and mucosal lesions. Choices A, B, and D are not typically associated with the medication's adverse effects. Hypotension is a common side effect of some medications but not the focus of monitoring for this specific drug. Prolonged wound healing is more related to factors like nutrition and comorbidities. Bradypnea (slow breathing) is not commonly associated with adverse effects of medications but could signify respiratory distress.
Which of the following actions is appropriate for the nurse to take?
- A. Obtain written consent from the client.
- B. Request verbal consent from the social worker.
- C. Contact the client's parents to obtain phone consent.
- D. Postpone the testing until the client's parents are present.
Correct Answer: A
Rationale: Correct Answer: A. Obtain written consent from the client.
Rationale: Written consent from the client is essential to ensure autonomy and informed decision-making. It shows respect for the client's rights and allows them to fully understand the procedure or treatment. Verbal consent may not provide a legal record of agreement. Contacting the client's parents without the client's consent may violate confidentiality and autonomy. Postponing testing can delay necessary healthcare. Written consent is the most appropriate choice to uphold ethical and legal standards in healthcare practice.
Which of the following recommendations should the nurse make?
- A. Store opened vials of insulin for up to 60 days.
- B. Follow up with physical therapy.
- C. Consult with a nutritionist.
- D. Monitor capillary blood glucose daily.
Correct Answer: C
Rationale: The correct recommendation is to consult with a nutritionist (Choice C). This is crucial in diabetes management as a nutritionist can provide personalized dietary guidance to help control blood sugar levels. By consulting with a nutritionist, the patient can learn about healthy eating habits, portion control, and meal planning tailored to their specific needs. This can lead to better blood glucose control and overall improved health outcomes. Storing opened vials of insulin for 60 days (Choice A) is incorrect as insulin should be discarded after a certain period to ensure its effectiveness. Following up with physical therapy (Choice B) may be beneficial for other health conditions but is not specifically related to managing diabetes. Monitoring capillary blood glucose daily (Choice D) is important but does not address the need for dietary adjustments which a nutritionist can provide.