An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?

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Question 1 of 5

An 8-year-old girl asks the nurse how the blood pressure apparatus works. What is the most appropriate nursing action?

Correct Answer: C

Rationale: The most appropriate nursing action when an 8-year-old girl asks how the blood pressure apparatus works is to explain in simple terms how it works. Children are curious by nature and providing a simple explanation in a language they can understand helps satisfy their curiosity and also promotes their understanding. By explaining how the blood pressure apparatus works, the nurse can educate the child about a common medical device and reduce any anxiety or fear the child may have about it. This approach encourages the child to feel more comfortable and engaged in their healthcare experience.

Question 2 of 5

An 8-day-old is admitted with vomiting and dehydration. His HR is 170, RR is 44, BP is 85/52, and T is 99°F. The parents ask if these vital signs are normal. Which is the best response?

Correct Answer: C

Rationale: A neonatal heart rate of 170 is above the normal range (90-160 bpm), which is concerning for dehydration.

Question 3 of 5

A patient is being given penicillin via IV piggyback and develops an anaphylactic reaction. Which of the following should be the nurse's first action?

Correct Answer: D

Rationale: In the scenario of a patient developing an anaphylactic reaction to penicillin via IV piggyback, the nurse's first action should be to discontinue the administration of the antibiotic to prevent further exposure and potential worsening of the reaction. Turning off the antibiotic is critical as it stops the source of the allergic reaction. This step takes precedence over any other actions including calling the doctor, maintaining the antibiotic, or calling for help, as stopping the infusion is the most immediate and important action to take in managing an anaphylactic reaction. Once the antibiotic has been turned off, the nurse can then proceed with providing appropriate emergency treatments and notifying the healthcare team for further management.

Question 4 of 5

The nurse is caring for a newborn receiving an exchange transfusion for hemolytic disease. Assessment of the newborn reveals slight respiratory distress and tachycardia. Which should the nurse's first action be?

Correct Answer: B

Rationale: Slight respiratory distress and tachycardia in a newborn during an exchange transfusion may indicate a possible transfusion reaction or overload. The first action the nurse should take is to stop the transfusion to prevent any further complications and assess the newborn's condition. After stopping the transfusion, the nurse can then take appropriate steps such as notifying the practitioner, administering medications, or providing supportive care as needed.

Question 5 of 5

A client with HIV has been prescribed anti viral medications. What instructions related to administration of medications should the nurse give such a client?

Correct Answer: A

Rationale: The nurse should instruct the client to comply with the timing of antiviral medication around meals. Taking some antiviral medications with food can help reduce gastrointestinal side effects. Certain medications may be more effective when taken with food, while others may need to be taken on an empty stomach. It is essential for the client to follow the specific instructions given by their healthcare provider to ensure the optimal effectiveness of the antiviral medications.

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