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Questions 163

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Extract:


Question 1 of 5

A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?

Correct Answer: C

Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.

Extract:

Laboratory reference ranges
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)

Female: 12.0–16.0 g/dL
(120–160 g/L)
WBC
5000–10,000/mm³
(5–10 × 10⁹/L)


Question 2 of 5

The nurse is collecting data from a client with acute diverticulitis. Which of the following findings would be essential to follow up?

Correct Answer: A

Rationale: Pain progressing to the left upper quadrant in diverticulitis is concerning for complications like perforation or abscess, requiring follow-up. Mild anemia and flexed positioning are common, and a moderately elevated WBC is expected in acute inflammation.

Extract:


Question 3 of 5

A woman brings her 6-month-old daughter to a clinic for a checkup and immunizations. The mother tells the nurse that her infant is cranky, has a bad cold, and has not eaten well the last days. She asks if the baby will still be able to get her shots. The child's temperature is 100.8°F. How should the nurse respond?

Correct Answer: B

Rationale: Mild fever and illness contraindicate vaccinations due to potential reduced immune response and difficulty distinguishing vaccine reactions from illness symptoms.

Question 4 of 5

When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?

Correct Answer: A

Rationale: It has no clear etiology. Enuresis has multiple contributing factors, but no single definitive cause has been established.

Question 5 of 5

The client is receiving a gentamicin IV. Which finding may indicate an adverse response to gentamicin?

Correct Answer: A

Rationale: Gentamicin is nephrotoxic; decreased urine output suggests kidney injury, a serious adverse effect. Other symptoms are not typically associated.

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