An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to:
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Solution
Answer B is correct. The medication should be administered using the calibrated dropper that comes with the medication. Answers A and C are incorrect because part or all of the medication could be lost during administration. Answer D is incorrect because part or all of the medication will be lost if the child does not finish the bottle
An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:
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Solution
Answer D is correct. The pulse oximeter should be placed on the child’s finger or earlobe because blood flow to these areas is most accessible for measuring oxygen concentration. Answer A is incorrect because the probe cannot be secured to the abdomen. Answer B is incorrect because it should be recalibrated before application. Answer C is incorrect because a reading is obtained within seconds, not minutes.
Which of the following findings is associated with right-sided heart failure?
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Solution
Answer B is correct. Increased voiding at night is a symptom of right-sided heart failure. Answers A and D are incorrect because they are symptoms of left-sided heart failure. Answer C does not relate to the client’s diagnosis; therefore, it is incorrect.
The best diet for the client with Meniere’s syndrome is one that is:
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Solution
Answer B is correct. A low-sodium diet is best for the client with Meniere’s syndrome. Answers A, C, and D do not relate to the care of the client with Meniere’s syndrome; therefore, they are incorrect.
Which of the following medication orders needs further clarification?
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Solution
Answer C is correct. There is no specified time or frequency for the ordered medication. Answers A, B, and D contain specified time and frequency, therefore they do not require further clarification.
Which of the following is a common complaint of the client with end-stage renal failure?
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Solution
Answer B is correct. Pruritis or itching is caused by the presence of uric acid crystals on the skin, which is common in the client with end-stage renal failure. Answers A, C, and D are not associated with end-stage renal failure.
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client’s confusion by:
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Solution
Answer D is correct. Leaving a nightlight on during the evening and night shifts helps the client remain oriented to the environment and fosters independence. Answers A and B will not decrease the client’s confusion. Answer C will increase the likelihood of confusion in an elderly client.
A client with glaucoma has been prescribed Timoptic (timolol) eyedrops. Timoptic should be used with caution in the client with a history of:
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Solution
Answer C is correct. Beta blockers such as timolol (Timoptic) can cause bronchospasms in the client with chronic obstructive lung disease. Timoptic is not contraindicated for use in clients with diabetes, gastric ulcers, or pancreatitis; therefore, answers A, B, and C are incorrect.
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
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Solution
Answer A is correct. The least restrictive restraint for the infant with cleft lip and cleft palate repair is elbow restraints. Answers B, C, and D are more restrictive and unnecessary; therefore, they are incorrect.
A mother of a 3-year-old hospitalized with lead poisoning asks the nurse to explain the treatment for her daughter. The nurse’s explanation is based on the knowledge that lead poisoning is treated with:
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Solution
Answer B is correct. Chelating agents are used to treat the client with poisonings from heavy metals such as lead and iron. Answers A and D are used to remove noncorrosive poisons; therefore, they are incorrect. Answer C prevents vomiting; therefore, it is an incorrect response.