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Which suggestion by the nurse would be most helpful in relieving the teenager's menstrual pain and discomfort?
- A. Stay in bed until cramping is relieved, increase your fluid intake, and eat a low-fat diet.
- B. Drink plenty of cold liquids, add extra salt to your diet, and take a nap in the afternoon.
- C. Apply ice packs to the abdomen, eat a high-calorie diet, and have your largest meal at noon.
- D. Get at least 8 hours of sleep, eat a well-balanced diet, and apply heat to your abdomen.
Correct Answer: D
Rationale: Applying heat to the abdomen relaxes uterine muscles, reducing cramping, while adequate sleep and a balanced diet support overall health, alleviating dysmenorrhea symptoms.
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Which assessment finding should the nurse report immediately to the charge nurse or physician?
- A. Clear, watery nasal drainage
- B. Glasgow Coma Scale score of 15
- C. Child does not know the time of day
- D. Apical pulse of 80 beats/minute
Correct Answer: A
Rationale: Clear, watery nasal drainage may indicate cerebrospinal fluid (CSF) leakage, a serious complication of head injury requiring immediate reporting to prevent infection or neurological damage.
Which of the following assessment findings would alert the nurse that the child may be exhibiting early signs of sepsis?
- A. Increased level of pain
- B. Disorientation
- C. Decreased urine output
- D. Jitteriness
Correct Answer: B
Rationale: Disorientation can indicate early sepsis in burn patients, reflecting systemic infection affecting the central nervous system. Other signs like fever or tachycardia may also occur, but disorientation is a critical early warning.
Which instruction is most appropriate to give to the client regarding doxycycline?
- A. The medication normally causes a dark orange discoloration of urine.
- B. Take the medication 1 hour before or 2 hours after a meal.
- C. Don't drink water for at least 30 minutes after taking the medication.
- D. Report any symptoms of GI upset to the health care provider.
Correct Answer: B
Rationale: Doxycycline should be taken on an empty stomach (1 hour before or 2 hours after a meal) to ensure optimal absorption, making this the most appropriate instruction.
The nurse would be correct to set the infusion pump for which hourly rate?
- A. 50 mL
- B. 75 mL
- C. 100 mL
- D. 125 mL
Correct Answer: D
Rationale: The order is 1,000 mL over 8 hours. Dividing 1,000 by 8 gives 125 mL/hour, the correct rate for the infusion pump.
The nurse is administering surfactant via ET tube to a 48-hour-old preterm infant with respiratory distress syndrome (RDS). The father asks the nurse how this treatment will help his baby. The nurse should explain that the preterm infant is unable to produce adequate amounts of surfactant and that giving it to his baby will have what effect?
- A. Increase PaCO2 levels in the bloodstream
- B. Prevent collapse of the alveoli
- C. Decrease PaO2 levels in the bloodstream
- D. Prevent pleural effusion
Correct Answer: B
Rationale: Surfactant prevents alveolar collapse in RDS improving gas exchange decreasing PaCO2 and increasing PaO2. Pleural effusion is unrelated.