A factory worker is brought to the nurse’s office after a metal fragment enters his right eye. The nurse should:
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Solution
Answer D is correct. The nurse should cover both of the client’s eyes and transport him immediately to the ER or the doctor’s office. Answers A, B, and D are incorrect because they increase the risk of further damage to the eye.
A toddler with otitis media has just completed antibiotic therapy. A recheck appointment should be made to:
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Solution
Answer C is correct. The client should be assessed following completion of antibiotic therapy to determine whether the infection has cleared. Answer A would be done if there are repeated instances of otitis media; therefore, it is incorrect. Answer B is incorrect because it will not determine whether the child has completed the medication. Answer D is incorrect because the purpose of the recheck is to determine whether the infection is gone.
Which of the following statements reflects Kohlberg’s theory of the moral development of the preschool-age child?
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Solution
Answer D is correct. According to Kohlberg, in the preconventional stage of development, the behavior of the preschool child is determined by the consequences of the behavior. Answers A, B, and C describe other stages of moral development; therefore, they are incorrect.
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
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Solution
Answer B is correct. The primary purpose for the continuous passive-motion machine is to promote flexion of the artificial joint. The device should be placed at the foot of the client’s bed. Answers A, C, and D do not describe the purpose of the CPM machine; therefore, they are incorrect.
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
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Solution
Answer B is correct. The client with a detached retina will have limitations in mobility before and after surgery. Answer A is incorrect because a detached retina produces no pain or discomfort. Answers C and D do not apply to the client with a detached retina; therefore, they are incorrect.
A client with insulin-dependent diabetes takes 20 units of NPH insulin at 7 a.m. The nurse should observe the client for signs of hypoglycemia at:
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Solution
Answer C is correct. The client taking NPH insulin should have a snack midafternoon to prevent hypoglycemia. Answers A and B are incorrect because the times are too early for symptoms of hypoglycemia. Answer D is incorrect because the time is too late and the client would be in severe hypoglycemia.
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
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Solution
Answer D is correct. Benzodiazepines are ordered for the client in alcohol withdrawal to prevent delirium tremens. Answer A is incorrect because it is a medication used in aversive therapy to maintain sobriety. Answer B is incorrect because it is used for the treatment of benzodiazepine overdose. Answer C is incorrect because it is the treatment for opiate withdrawal.
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:
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Solution
Answer A is correct. The client taking Cytoxan should increase his fluid intake to prevent hemorrhagic cystitis. Answers B, C, and D do not relate to the question; therefore, they are incorrect.
The LPN is preparing to administer an injection of vitamin K to the newborn. The nurse should administer the injection in the:
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Solution
Answer B is correct. The nurse should administer the injection in the vastus lateralis muscle. Answers A and C are not as well developed in the newborn; therefore, they are incorrect. Answer D is incorrect because the dorsogluteal muscle is not used for IM injections until the child is 3 years of age.
Which of the following meal choices is suitable for a 6-month-old infant?
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Solution
Answer C is correct. Rice cereal, apple juice, and formula are suitable foods for the 6-month-old infant. Whole milk, orange juice, and eggs are not suitable for the young infant; therefore, they are incorrect.