The nurse is caring for an 80-year-old with chronic bronchitis. Upon the morning rounds, the nurse finds an O2 sat of 76%. Which of the following actions should the nurse take first?
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Solution
Apply oxygen by mask
Remember the ABCs (airway, breathing, circulation) when answering this question. Before notifying the physician or assessing the pulse, oxygen should be applied to increase the oxygen saturation, so answers A and D are incorrect. The normal oxygen saturation for a child is 92%–100%, making answer B incorrect.
The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
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Solution
Cheese omelet
The child with celiac disease should be on a gluten-free diet.
Options A, B, and C: These food items all contain gluten.
A 25-year-old client with Grave’s disease is admitted to the unit. What would the nurse expect the admitting assessment to reveal?
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Solution
Exophthalmos
Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism.
Options A, B, and D: The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss.
The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
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Solution
A tracheostomy set
For a child with epiglottitis and the possibility of complete obstruction of the airway, emergency tracheostomy equipment should always be kept at the bedside.
Options A, C, and D: Intravenous supplies, fluid, and oxygen will not treat an obstruction.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
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Solution
High fever
If the child has bacterial pneumonia, a high fever is usually present.
Option B: Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough.
Options C and D: Rhinitis is often seen with viral pneumonia, and vomiting and diarrhea are usually not seen with pneumonia.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
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Solution
Risk for aspiration
Always remember your ABCs (airway, breathing, circulation) when selecting an answer.
Option A: does not apply for a child who has undergone a tonsillectomy.
Options B and D: Although these nursing diagnoses might be appropriate for this child, risk for aspiration should have the highest priority.
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
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Solution
Answer: B. Store the hearing aid in a warm place.
The hearing aid should be stored in a warm, dry place.
- Option A: It should be cleaned daily but should not be moldy.
- Option C: A toothpick is inappropriate to use to clean the aid; the toothpick might break off in the hearing aid.
- Option D: Changing the batteries weekly is not necessary.
A 2-year-old toddler is admitted to the hospital. Which of the following nursing interventions would you expect?
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Solution
Answer: C. Ask the parent/guardian to room-in with the child.
The nurse should encourage rooming-in to promote parent-child attachment. It is okay for the parents to be in the room for assessment of the child.
- Options A and B: Allowing the child to have items that are familiar to him is allowed and encouraged.
- Option D: Telling the child that screaming is inappropriate behavior is not part of the nurse’s responsibilities.
The nurse is discussing meal planning with the mother of a 2-year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
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Solution
Answer: C. “We are going on a camping trip this weekend, and I have bought hot dogs to grill for his lunch.”
Remember the ABCs (airway, breathing, circulation) when answering this question. Answer C because a hotdog is the size and shape of the child’s trachea and poses a risk of aspiration.
Options A, B, and D: A white grape juice, grilled cheese sandwich, and ice cream do not pose a risk of aspiration for a child.
The nurse is caring for a 6-year-old client admitted with a diagnosis of conjunctivitis. Before administering eye drops, the nurse should recognize that it is essential to consider which of the following?
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Solution
Answer: A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
Before instilling eye drops, the nurse should cleanse the area with water.
- Option B: A 6-year-old child is not developmentally ready to instill his own eyedrops.
- Option C: Although the mother of the child can instill the eye drops, the area must be cleansed before administration.
- Option D: Although the eye might appear to be clear, the nurse should instill the eyedrops, as ordered, so answer D is incorrect.