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Questions 158

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Question 1 of 5

The priority nursing goal when working with an autistic child is:

Correct Answer: A

Rationale: The priority nursing goal when working with an autistic child is establishing a trusting relationship. Maintaining a relationship with the family is important but having the trust of the child is a priority.
To promote involvement in school activities is inappropriate for a child who is autistic. Maintaining nutritional requirements is not the primary problem of the autistic child.

Question 2 of 5

A burn victim's immunization history is assessed by the nurse. Which immunization is of priority concern?

Correct Answer: C

Rationale: Tetanus toxoid prevents tetanus. Tetanus is transmitted through contaminated wounds.

Question 3 of 5

To prevent fungal infections of the mouth and throat, the nurse should teach clients on inhaled steroids to:

Correct Answer: B

Rationale: It is sufficient to rinse the plastic holders with warm water at least once per day. It is important to rinse the mouth after each use to minimize the risk of fungal infections by reducing the droplets of the glucocorticoid left in the oral cavity. Antacids act by neutralizing or reducing gastric acid, thus decreasing the pH of the stomach. 'Neutralizing' the oral mucosa prior to inhalation of a steroid inhaler does not minimize the risk of fungal infections. Rinsing prior to the use of the glucocorticoid will not eliminate the droplets left on the oral mucous membranes following the use of the inhaler.

Question 4 of 5

A client diagnosed with bipolar disorder continues to be hyperactive and to lose weight. Which of the following nutritional interventions would be most therapeutic for him at this time?

Correct Answer: A

Rationale: The manic client is unable to sit still long enough to eat an adequate meal. Small, frequent feedings with finger foods allow him to eat during periods of activity. This type of therapy should be implemented when other methods have been exhausted. The manic client should not be in control of his treatment plan. This type of client may forget to eat. The manic client is unable to sit down to eat full meals.

Question 5 of 5

The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?

Correct Answer: A

Rationale: Amphotericin B should be mixed with D5W, not normal saline, due to stability issues. Slow infusion (
B), hydration (
C), and premedication (
D) are standard practices.

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