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- The nurse reinforces home care instructions to the parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?
- "We need to encourage adequate fluid intake."
- "Coughing spells may be triggered by dust or smoke."
- "We need to maintain respiratory precautions and a quiet environment for at least 2 weeks."
- "Good hand-washing techniques need to be instituted
to prevent spreading the disease to others." - ANSWERS-
Rationale: Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage. Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 4 are components of home care instructions. Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Options 1 and 4 can be easily eliminated because they are general interventions associated with convalescence. Knowing that coughing spells are associated with pertussis will assist in directing you to the correct option
from the remaining options. In addition, a 2-week period of respiratory precautions is not required. Review: home care instructions for the child with pertussis. Level of Cognitive Ability: Evaluating Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process/Evaluation Content Area: Child Health: Infectious and Communicable Diseases Priority Concepts: Gas Exchange, Infection Reference(s): Hockenberry, Wilson (2013), pp. 428, 653-
A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.
Monitor the vital signs.
Monitor intake and output.
Increase water intake orally.
Monitor the electrolyte levels.
Provide a sodium-reduced diet.
6. Administer sodium replacements. - ANSWERS-742. 1,
4. A glycosylated hemoglobin level of 12% - ANSWERS-
Rationale: Glipizide (Glucotrol) is an oral hypoglycemic agent administered to decrease the serum glucose level and the signs and symptoms of hyperglycemia. Therefore, a decrease in both polyuria and polyphagia would indicate a therapeutic response. Laboratory values are also used to monitor a client's response to treatment. A fasting blood glucose level of 100 mg/dL is within normal limits. However, glycosylated hemoglobin of 12% indicates poor glycemic control. Test-Taking Strategy: Focus on the subject, an ineffective response to the medication. Recalling that glipizide is an oral hypoglycemic agent tells you to look for an option that would indicate hyperglycemia (lack of response to the medication). Options 1 and 2 are comparable or alike options and are eliminated first. Next, eliminate option 3 because it is a normal blood glucose level. Review: glipizide (Glucotrol). Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Pharmacology: Endocrine Medications Priority Concepts: Adherence, Glucose Regulation Reference(s): deWit, Kumagai (2013), pp. 827, 862.
- The nurse is reinforcing discharge instructions to a client receiving sulfisoxazole. Which should be included in the plan of care for instructions?
- Maintain a high fluid intake.
- Discontinue the medication when feeling better.
- If the urine turns dark brown, call the health care provider immediately.
- Decrease the dosage when symptoms are improving to
prevent an allergic response. - ANSWERS-744. 1
Rationale: Each dose of sulfisoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfisoxazole cause the urine to turn dark brown or red. This does not indicate the need to notify the health care provider. Test-Taking Strategy: Focus on the subject, instructions for a client taking a sulfonamide. General principles related to medication administration will assist in eliminating options 2 and 4. Options 2 and 4 are also comparable or alike options. Next, it is necessary to know that the client should maintain a high fluid intake. Review: sulfisoxazole. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Content Area: Pharmacology: Renal and Urinary Medications Priority Concepts: Client Education, Elimination Reference(s): deWit, Kumagai (2013), p.
Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health: Gastrointestinal Priority Concepts: Clinical Judgment, Nutrition Reference(s): Cooper, Gosnell (2015), pp. 676, 680.
- A postoperative client requests medication for flatulence (gas pains). Which medication from the following PRN list should the nurse administer to this client?
- Ondansetron (Zofran)
- Simethicone (Mylicon)
- Acetaminophen (Tylenol)
- Magnesium hydroxide (milk of magnesia, MOM) -
ANSWERS-746. 2
Rationale: Simethicone is an antiflatulent used in the relief of pain caused by excessive gas in the gastrointestinal tract. Ondansetron is used to treat postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic. Magnesium hydroxide is an antacid and laxative. Test-Taking Strategy: Note the subject, a medication to treat flatulence (gas pains). Recalling the classifications of the medications in the options will direct you to the correct option. Review: simethicone (Mylicon). Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation
Content Area: Pharmacology: Gastrointestinal Medications Priority Concepts: Clinical Judgment, Pain Reference(s): Hodgson, Kizior (2015), pp. 1104-1105.
- A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice?
- Weigh the client three times per week, before breakfast.
- Explain to the client the importance of a good nutritional intake.
- Report the nutritional concern to the psychiatrist and obtain a nutritional consult as soon as possible.
- Offer the client several small, frequent meals daily, and schedule brief nursing interactions with the client during
these times. - ANSWERS-747. 4
Rationale: Change in appetite is one of the major symptoms of depression. Offering the client several small, frequent meals and the nurse's presence at that time to support, encourage, or perhaps even feed the client is the most appropriate intervention. A client with depression experiences poor concentration and will not understand the importance of an adequate nutritional intake. Weighing the client does not address how to increase nutritional intake. Reporting the nutritional problems to the psychiatrist is correct to some degree, but it does not address how one might increase food intake.
Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Pharmacology: Endocrine Medications Priority Concepts: Clinical Judgment, Glucose Regulation Reference(s): Lehne (2013), p. 712.
- The nurse assists in developing a plan of care for a client with hyperparathyroidism receiving calcitonin- human (Cibacalcin). Which outcome has the highest priority regarding this medication?
- Relief of pain
- Absence of side effects
- Reaching normal serum calcium levels
- Verbalization of appropriate medication knowledge -
ANSWERS-
- The nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor which fact about hemophilia?
- Hemophilia is a Y-linked hereditary disorder.
- A splenectomy resolves the bleeding disorders.
- Hemophilia A results from deficiency of factor VIII.
- A bone marrow transplant is the treatment of choice. -
ANSWERS-
- A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse understands that which diagnostic study should confirm this diagnosis?
- A platelet count
- A lumbar puncture
- Bone marrow biopsy
4. White blood cell (WBC) count - ANSWERS-
- A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea?
- Low-calorie foods
- Cool, clear liquids
- Low-protein foods
4. The child's favorite foods - ANSWERS-
- To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?
- Initiating seizure precautions
- Using a wheelchair for out-of-bed activities
- Assisting the child with ambulation at all times
- Avoiding contact with other children on the nursing unit
- Stop nursing during the period of nipple soreness to allow the nipples to heal.
- Nurse the newborn infant less frequently and substitute a bottle feeding until the nipples become less sore.
- Position the newborn infant with the ear, shoulder, and hip in straight alignment and with the baby's stomach
against the mother's. - ANSWERS-
- On data collection, which behavior should the nurse expect a client diagnosed with agoraphobia to describe?
- A fear of leaving the house
- A fear of riding in elevators
- A fear of speaking in public
- A fear of uncleanliness and the need to bathe every
hour - ANSWERS-
- The nurse checks the food on a tray delivered for an Orthodox Jewish client and notes that the client has received a cheeseburger and potato fries with whole milk as a beverage. Which action should the nurse take?
- Deliver the food tray to the client.
- Replace the whole milk with lactose-free milk.
- Call the dietary department and ask for a different meal.
- Ask the dietary department to replace the beef with
pork. - ANSWERS-
- A client is brought to the emergency department by the ambulance team after collapse at home. Cardiopulmonary resuscitation is attempted but is unsuccessful. The wife of the client tells the nurse that the client is an organ donor and that his eyes are to be donated. Which action should the nurse take next?
- Place dry, sterile dressings over the eyes of the deceased.
- Call the National Donor Association to confirm that the client is a donor.
- Close the eyes, elevate the head of the bed, and place a small ice pack on the eyes.
- Ask the wife to obtain the legal documents regarding
organ donation from the lawyer. - ANSWERS-
- The nurse prepares to administer a prescribed dose of scopolamine (Transderm-Scop). The nurse should monitor for which side effect of this medication?
- Dry mouth
- Diaphoresis
- Excessive urination
4. Pupillary constriction - ANSWERS-
- The nurse is caring for a newborn diagnosed with Down syndrome. The parents are asking questions about the disorder. The nurse should provide which information when discussing Down syndrome?
4. Prolonged PR interval - ANSWERS-
- An adult client with hepatic encephalopathy has a serum ammonia level of 120 mcg/dL and receives treatment with lactulose (Chronulac) syrup. The nurse determines that the client has the best response if the level changes to which after medication administration?
- 2 mcg/dL
- 5 mcg/dL
- 70 mcg/dL
4. 100 mcg/dL - ANSWERS-
- The nurse assists in developing a plan of care for the child with meningitis. Which would be the priority client problem for a child with a meningitis diagnosis?
- Pain
- Inadequate knowledge
- Neurological dysfunction
4. Difficult family coping processes - ANSWERS-
- The nurse is caring for a postoperative client who has been NPO and the health care provider has prescribed a clear liquid diet. In planning to initiate this diet, which priority item should the nurse place at the client's bedside?
- A straw
- Code cart
- Blood pressure cuff
4. Suction equipment - ANSWERS-
- The nurse reinforces client instructions about ethambutol (Myambutol). The nurse determines that the client understands the instructions if the client indicates to report which occurrence?
- Impaired sense of hearing
- Distressing gastrointestinal side effects
- Orange-red discoloration of body secretions
- Difficulty discriminating the color red from green -
ANSWERS-
- The nurse is caring for an older client with a diagnosis of myasthenia gravis and has reinforced self- care instructions. Which statement by the client indicates a need for further teaching?
- "I rest each afternoon after my walk."
- "I cough and deep breathe many times during the day."
- "If I get abdominal cramps and diarrhea, I should call my doctor."
- "I can change the time of my medication on the
mornings that I feel strong." - ANSWERS-
- The nurse should implement which in the care of a child who is having a seizure? Select all that apply.
- Time the seizure.
- Tachycardia
- Nervousness
4. Low blood glucose level - ANSWERS-
- The nurse is asked to regulate the flow rate of an intravenous (IV) solution being administered to a client. The IV bag contains 50 mL of solution and the solution is to be administered over 30 minutes. The administration set has a drop factor of 10 drops (gtts)/mL. The nurse should regulate the roller clamp on the infusion set to deliver how many drops per minute? Fill in the blank. Round answer to the nearest whole number.
Answer: ___________ gtts/minute - ANSWERS-
- Which data would indicate a potential complication associated with age-related changes in the musculoskeletal system?
- Decrease in height
- Overall sclerotic lesions
- Diminished lean body mass
4. Changes in structural bone tissue - ANSWERS-
- The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching?
- "I need to check for jaundiced skin and eyes every day."
- "I need to have my child nap during the day to provide rest."
- "I need to decrease the stimuli at home to prevent intracranial pressure."
- "I need to give frequent, small, nutritious meals if my
child starts to vomit." - ANSWERS-
- A health care provider prescribes potassium chloride (KCl) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCl), 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose? Fill in the blank.
Answer: ________________ mL - ANSWERS-
- The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy?
- "Antacids will coat my stomach."
- "Omeprazole (Prilosec) will coat the ulcer and help it heal."
- "Sucralfate (Carafate) will change the fluid in my stomach."
- "The nizatidine (Axid) will cause me to produce less
stomach acid." - ANSWERS-
