Nokea
A one-year-old child.
While doing a physical examination of a one-year-old child, which of the following assessments should be done by the nurse LAST?
- A. Take a rectal temperature.
- B. Auscultate the breath sounds.
- C. Auscultate the apical heart rate.
- D. Evaluate motor functions.
Correct Answer: A
Rationale: Strategy: Picture the situation. (1) correct-all invasive procedures should be done last, so as not to alter cardiopulmonary assessment of the child (2) should be done before a rectal temperature (3) should be done before a rectal temperature (4) should be done before a rectal temperature
You may also like to solve these questions
The client is discharged from the unit with a prescription for Evista (raloxifene HCl). Which of the following is a side effect of this medication?
- A. Leg cramps
- B. Hot flashes
- C. Urinary frequency
- D. Cold extremities
Correct Answer: B
Rationale: Evista, used for osteoporosis, has an estrogen agonist effect, commonly causing hot flashes. It does not cause leg cramps , urinary frequency , or cold extremities .
Two new admissions to the unit. One of the new admissions is diagnosed with pneumonia, and the other new patient is diagnosed with AIDS.
Which of the following assignments is MOST appropriate?
- A. Assign both patients to one room with one nurse caring for both patients.
- B. Place both patients in the same room and assign the care to different nurses.
- C. Assign each patient to a private rooms and assign both clients to one nurse.
- D. Place each client in a private room and assign each patient to a different nurse.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) increases the potential for transmission of infection (2) keeps the clients in the same room; should not be done (3) puts them in separate rooms but same nurse is caring for them (4) correct-to prevent spread of infection, clients should have private rooms with different nurses
The nurse is caring for clients in outpatient surgery.
- A. What is the best statement by the nurse to the mother of a four-year-old preparing for eye surgery?
- B. Draw a picture of the eye to explain what will happen.'
- C. Tell your daughter that the procedure will take one hour.'
- D. Use dolls or puppets to explain how to get ready for surgery.'
- E. Read an age-appropriate illustrated book about eye surgery to your daughter.'
Correct Answer: C
Rationale: For a four-year-old, using dolls or puppets to demonstrate the procedure in simple terms is developmentally appropriate, addressing what the child will experience (see, hear, feel). Drawing pictures or reading books is better for school-aged children, and time concepts like one hour are not relatable to preschoolers.
The nursing team consists of an RN who has been practicing for 6 months, a LPN/LVN who has been practicing for 15 years, and a nursing assistant who has been caring for clients for 3 years. The RN should care for which of the following clients?
- A. A client 1-day postoperative after an internal fixation of a fractured left femur.
- B. A client receiving diltiazem (Cardizem) and phenytoin (Dilantin).
- C. A client who is to receive 2 units of packed cells prior to an upper endoscopy procedure.
- D. A client admitted yesterday with exhaustion and a diagnosis of acute bipolar disorder.
Correct Answer: C
Rationale: Blood transfusions require RN assessment and teaching due to risks like transfusion reactions. Options A, B, and D can be assigned to the nursing assistant (postop care) or LPN (medication administration, bipolar care), as they involve standard procedures.
Which of the following is the BEST method for the nurse to use when evaluating the effectiveness of tracheal suctioning?
- A. Note subjective data, such as 'My breathing is much improved now.'
- B. Note objective findings, such as decreased respiratory rate and pulse.
- C. Consult with the respiratory therapist to determine effectiveness.
- D. Auscultate the chest for change or clearing of adventitious breath sounds.
Correct Answer: D
Rationale: to assess the effectiveness of suctioning, auscultate the client's chest to determine if the adventitious sounds are cleared and to ensure that the airway is clear of secretions.