Mechanic
A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching?
1) Apply a topical corticosteroid ointment to the affected area.
2) Launder the child's clothing with fabric softener.
3) Give the child a bubble baths every day.
4) Dress the child in woolen clothes during cold months.
1) Apply a topical corticosteroid ointment to the affected area.
Answer Rationale:
The child might require a topical corticosteroid ointment to use during flare-ups to decrease inflammation.
A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority?
1) Respiratory rate
2) Burns of the mouth
3) Bowel sounds
4) Visual acuity
1) Respiratory rate
Answer Rationale:
Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing can follow. In severe cases, brain damage can occur.
A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care?
1) Place the client in a semi-Fowler's position.
2) Admit the client to a private room.
3) Measure head circumference every shift.
4) Implement seizure precautions.
3) Measure head circumference every shift.
Answer Rationale:
The head circumference of a 6-year-old can't increase since the fontanels and sutures have been closed since the child was 18 months old. Therefore, it is unnecessary to measure the child's head circumference.
A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take?
1) Offer fluids through a straw.
2) Apply bilateral wrist restraints.
3) Administer opioids for pain.
4) Implement a soft diet.
3) Administer opioids for pain.
Answer Rationale:
Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates an understanding of the teaching?
1) "It's okay to have a couple of glasses of wine with dinner each evening."
2) "I'll be sure to eat more foods with vitamin K."
3) "I'll take aspirin for my headaches."
4) "I'll use my electric razor for shaving."
4) "I'll use my electric razor for shaving."
Answer Rationale:
Because this medication prolongs clotting times, the client should avoid situations that put him at high risk for bleeding, such as shaving with a straight razor or a razor blade.
A nurse in a clinic is assessing a 7-month-old infant. Which of the following indicates a need for further evaluation?
1) Uses a unidextrous grasp
2) Has a fear of strangers
3) Shows preferences towards foods
4) Babbles one-syllable sounds
4) Babbles one-syllable sounds
Answer Rationale:
A 7-month-old infant should babble in chained syllables such as mama and baba, and babble four distinct vowel sounds; therefore, this finding indicates a need for further evaluation.
A nurse on a medical unit is assessing four clients for urinary retention. Which of the following clients have manifestations of urinary retention?
1) A client who has an elevated BUN
2) A client who reports painful urination
3) A client who reports urinary frequency
4) A client who has glucose in his urine
3) A client who reports urinary frequency
Answer Rationale:
Voiding a small amount of urine (less than 100 mL) frequently (2 to 3 times per hr), and dribbling of urine are manifestations of urinary retention.
A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?
1) "Has your son had a sore throat recently?"
2) "Was your son born with this cardiac defect?"
3) "Has your child had any injuries recently?"
4) "Have you given your child aspirin in the past 2 weeks?"
1) "Has your son had a sore throat recently?"
Answer Rationale:
Rheumatic fever typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to determine whether the child previously had a sore throat.
A nurse is administering an enteral feeding through a client's NG tube. Which of the following actions should the nurse take?
1) Keep the formula cold until instillation.
2) Withhold the feeding if the residual volume is 150 mL.
3) Cleanse the top of the can of formula with an alcohol wipe.
4) Flush the tube with 30 mL of sterile water before the feeding.
3) Cleanse the top of the can of formula with an alcohol wipe.
Answer Rationale:
Surface bacteria and dust can contaminate the top of formula cans, so the nurse should disinfect them before opening them and introducing contaminants into the formula. The nurse should allow the can to air-dry before opening it to avoid introducing alcohol into the formula.
A client receives a wrong medication. The nurse who made the medication error should take which of the following actions first?
1) Complete an incident report.
2) Notify the nurse manager.
3) Assess the client.
4) Call the client’s provider.
3) Assess the client.
Answer Rationale:
The first action the nurse should take using the nursing process is to assess the client. The nurse must first determine whether or not the error has caused the client any harm and also provide any relevant interventions.
A nurse is orienting a newly licensed nurse in the care of an infant who has myelomeningocele. Which of the following actions by the new nurse indicates the teaching has been effective?
1) Performs range of motion on the infant's hips
2) Maintains a dry dressing over the sac
3) Takes an axillary temperature
4) Places the infant in a side-lying position
3) Takes an axillary temperature
Answer Rationale:
Rectal temperatures should be avoided in infants who have spina bifida due to the risk for irritation and rectal prolapse.
A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make?
1) "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better."
2) "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me."
3) "Your child did not seem upset, so I wouldn't worry about it if I were you."
4) "Why does it bother you that your child has wet the bed?"
1) "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better."
Answer Rationale:
A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. The nurse should reassure the parents that regression is an expected behavior in children who are hospitalized and that her child will regain bladder control when she is feeling better.
A nurse is preparing to administer digoxin to a client who has heart failure. Which of the following actions is appropriate?
1) Withholding the medication if the heart rate is above 100/min
2) Instructing the client to eat foods that are low in potassium
3) Measuring apical pulse rate for 30 seconds before administration
4) Evaluating the client for nausea, vomiting, and anorexia
4) Evaluating the client for nausea, vomiting, and anorexia
Answer Rationale:
Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity.
A nurse is reinforcing teaching about nutritional considerations with the parents of a toddler. Which of the following statements by the parents indicates an understanding of the teaching?
1) "I should expect him to have an increased appetite."
2) "His average daily intake should be about 3,000 calories."
3) "The quality of food I provide him is more important than the quantity."
4) "Because he is such a picky eater, I will give him one of my vitamins each day."
3) "The quality of food I provide him is more important than the quantity."
Answer Rationale:
Toddlers are very picky eaters and usually eat only one or two meals each day. Therefore, it is essential that the meals are balanced with essential nutrients. The nutritious quality of the food is much more important than the quantity. Toddlers generally prefer finger foods because of increasing autonomy.
A nurse is planning care for a child who has mumps. Which of the following instructions should the nurse include in the plan?
1) Initiate standard precautions.
2) Initiate airborne precautions.
3) Initiate droplet precautions.
4) Initiate contact precautions.
3) Initiate droplet precautions.
Answer Rationale:
Mumps is a contagious infection transmitted by large droplets. Therefore, initiating droplet precautions is appropriate for the nurse to include in the plan of care.
A nurse is assessing an 8-month-old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?
1) Tracks an object with eyes
2) Sits with pillow props
3) Smiles when a parent appears
4) Uses a pincer grasp to pick up a toy
2) Sits with pillow props
Answer Rationale:
Infants who have cerebral palsy require support when sitting upright.
A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid?
1) Broth
2) Water
3) Diluted apple juice
4) Oral rehydration solution
4) Oral rehydration solution
Answer Rationale:
Oral rehydration solution is the fluid of choice for infants and children who have dehydration due to diarrhea.
A nurse in the emergency department is caring for a client who took 3 nitroglycerin tablets sublingually for chest pain. The client reports relief from the chest pain but now he is experiencing a headache. Which of the following statements should the nurse make?
1) "A headache is an indication of an allergy to the medication."
2) "A headache is an expected adverse effect of the medication."
3) "A headache indicates tolerance to the medication."
4) "A headache is likely due to the anxiety about the chest pain."
2) "A headache is an expected adverse effect of the medication."
Answer Rationale:
The vasodilation nitroglycerin induces increases blood flow to the head and typically results in a headache.
A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?
1) Obtain a throat culture.
2) Place the child in an upright position.
3) Transport the child to radiology for a throat x-ray.
4) Visualize the epiglottis with a tongue depressor.
2) Place the child in an upright position.
Answer Rationale:
Placing the child in an upright position will assist in maintaining a patent airway.
A nurse is teaching a client who has a new prescription for fluoxetine to treat depression. Which of the following statements by the client indicates an understanding of the teaching?
1) "I should expect to feel better after 24 hours of starting this medication."
2) "I should not take this medicine with grapefruit juice."
3) "I'll take this medicine with food."
4) "I'll take this medicine first thing in the morning."
4) "I'll take this medicine first thing in the morning."
Answer Rationale:
The client should take fluoxetine in the morning to reduce the risk for insomnia.
A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?
1) Give with a 240 mL (8 oz) glass of milk.
2) Administer at mealtimes.
3) Give with orange juice.
4) Administer at bedtime.
3) Give with orange juice.
Answer Rationale:
Citrus fruit or juice aids absorption of this medication.
A nurse is administering a cleansing enema to a client who reports mild cramping. The client asks the nurse to stop the enema and allow him to go to the bathroom. Which of the following actions should the nurse take?
1) Discontinue the enema.
2) Slow the flow of enema solution briefly.
3) Continue the enema and reassure the client.
4) Pause the enema and administer oral pain medication.
2) Slow the flow of enema solution briefly.
Answer Rationale:
Slowing the enema solution flow temporarily prevents cramping.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
1) Place a pillow under the child's head.
2) Position the child side-lying.
3) Loosen restrictive clothing.
4) Clear the area of hazards.
2) Position the child side-lying.
Answer Rationale:
This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.
A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse's priority?
1) Insert an IV catheter.
2) Obtain blood culture specimens.
3) Administer an antipyretic.
4) Prepare for nasotracheal intubation.
4) Prepare for nasotracheal intubation.
Answer Rationale:
The client's manifestations suggest epiglottitis, which is a respiratory emergency. Airway obstruction is imminent, and that is the greatest risk to the client's safety at this time, so the priority action is to prepare for intubation to maintain airway patency.
A nurse is caring for a client who has hypernatremia and requires IV fluid therapy due to his NPO status. Which of the following solutions should the nurse prepare to infuse for this client?
1) Lactated Ringer's
2) Dextrose 5% in 0.9% sodium chloride
3) 0.45% sodium chloride
4) Dextrose 10% in water
3) 0.45% sodium chloride
Answer Rationale:
A client who has an elevated sodium level and is NPO requires a hypotonic IV solution, such as 0.45% sodium chloride or 0.225% sodium chloride.