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Questions 164

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Extract:


Question 1 of 5

The nurse is caring for assigned clients. The nurse should first check the

Correct Answer: A

Rationale: A 3-year-old with fever, hip pain, and refusal to move the leg (
A) may indicate a serious condition like septic arthritis or osteomyelitis, requiring immediate assessment to prevent joint damage or systemic infection. Sinus congestion (
B) and urinary symptoms (
D) are less urgent, and the nosebleed (
C) is being managed with pressure, making them lower priorities.

Question 2 of 5

The nurse is reinforcing home care instructions for the parents of a child diagnosed with rotavirus infection. Which of the following statements by the parents indicate that the teaching has been effective? Select all that apply.

Correct Answer: A,B,E

Rationale: Handwashing (
A), monitoring dehydration (
B), and recognizing transmission routes (E) are correct. Waiting to breastfeed (
C) delays nutrition, and alcohol wipes (
D) irritate skin, indicating ineffective teaching.

Question 3 of 5

A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?

Correct Answer: B

Rationale: Avoiding hair-fixing (
B) prevents arm movement that could dislodge leads, showing effective teaching. Device firing (
A) can be uncomfortable, driving (
C) is restricted temporarily, and air travel (
D) is generally safe with precautions.

Question 4 of 5

A nurse discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse’s first action?

Correct Answer: D

Rationale: Suctioning the mouth (
D) clears mucus, addressing potential airway obstruction causing cyanosis. Oxygen (
A), auscultation (
B), and positioning (
C) are secondary until the airway is clear.

Question 5 of 5

The nurse is reviewing new medication prescriptions for a client with an acute exacerbation of asthma. Which of the following prescriptions should the nurse clarify?

Correct Answer: B

Rationale: Potassium chloride (
B) is not indicated for asthma exacerbation unless hypokalemia is documented, requiring clarification. Albuterol (
A), methylprednisolone (
D) treat asthma, and enoxaparin (
C) may prevent thrombosis in immobile patients.

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