Nokea
While giving care to a 2 year-old client, the nurse should remember that the toddler's tendency to say 'no' to almost everything is an indication of what psychosocial skill?
- A. Stubborn behavior
- B. Rejection of parents
- C. Frustration with adults
- D. Assertion of control
Correct Answer: D
Rationale: Assertion of control. Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence.
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The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
- A. Increased blood pressure
- B. Inability to concentrate
- C. Dilated pupils
- D. Decreased heart rate
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
The nurse is caring for a client in the coronary care unit. The display on the cardiac monitor indicates ventricular fibrillation. What should the nurse do first?
- A. Perform defibrillation
- B. Administer epinephrine as ordered
- C. Assess for presence of pulse
- D. Institute CPR
Correct Answer: C
Rationale: Assess for presence of pulse. Verifying the absence of a pulse confirms ventricular fibrillation before proceeding with treatment.
A LPN/LVN contacts the nurse to say that s/he has shingles on her/his back. Which of the following statements by the nurse is BEST?
- A. You can't take care of clients for fourteen days.
- B. Come to work as scheduled.
- C. You can't care for clients until the lesions are crusted.
- D. Please contact your physician.
Correct Answer: B
Rationale: Localized shingles allows work if lesions are covered, as with back lesions. Options A, C, and D are overly restrictive or unnecessary.