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Questions 164

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Question 1 of 5

An 18 month-old has been brought to the emergency room with irritability, lethargy over 2 days, dry skin, and increased pulse. Based upon the evaluation of these initial findings, the nurse would assess the child for additional findings of

Correct Answer: B

Rationale: Dehydration. These symptoms are consistent with dehydration, requiring further assessment for fluid status.

Question 2 of 5

The nurse is assisting with the care of a newborn during circumcision. Which intervention is appropriate?

Correct Answer: D

Rationale: Wrapping the upper body keeps the newborn warm and secure during circumcision. Sterile technique is required, snug diapers risk irritation, and feeding during the procedure poses a choking risk.

Question 3 of 5

The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in

Correct Answer: C

Rationale: Sodium. The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.

Question 4 of 5

Following visitation, the nurse observes a client's wife sitting alone crying. When approached, the wife states, 'I'm so worried about him.' The best response by the nurse is:

Correct Answer: B

Rationale: Tell me what is worrying you' encourages the wife to express her concerns, facilitating support. Other responses assume causes or defer to others prematurely.

Question 5 of 5

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

Correct Answer: C

Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.

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