While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Questions 72

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Question 1 of 9

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 2 of 9

While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate?

Correct Answer: A

Rationale: The correct answer is A: 'Elevated blood pressure must be anticipated and identified quickly.' Acute glomerulonephritis can lead to significant hypertension, making it crucial to monitor blood pressure frequently to promptly identify any elevation. Choice B is incorrect because while monitoring can help assess medication effectiveness, the primary reason for frequent blood pressure checks in this case is to detect elevated blood pressure. Choice C is incorrect as not all hospitalized children require such frequent blood pressure monitoring. Choice D is incorrect as the primary reason for monitoring blood pressure is to detect hypertension, rather than solely focusing on potential kidney damage.

Question 3 of 9

While caring for a toddler receiving oxygen (02) via face mask, the nurse observes that the child's lips and nares are dry and cracked. Which intervention should the nurse implement?

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 9

A client who is at 10-weeks gestation calls the clinic because she has been vomiting for the past 24 hours. The nurse determines that the client has no fever. Which instructions should the nurse give to this client?

Correct Answer: A

Rationale: The correct answer is to advise the client to come to the clinic to be seen by a healthcare provider. Persistent vomiting during pregnancy can lead to dehydration, which requires medical evaluation. Choice B is incorrect because solely increasing fluid intake and resting at home may not be sufficient to address the potential dehydration and underlying causes of vomiting. Choice C is not recommended without medical evaluation, as over-the-counter antiemetics should be used under healthcare provider guidance during pregnancy. Choice D is not the best option here because with persistent vomiting and risk of dehydration, immediate medical assessment is crucial to ensure the well-being of both the client and the fetus.

Question 5 of 9

The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value requires immediate intervention?

Correct Answer: A

Rationale: A serum potassium level of 5.5 mEq/L is most concerning in a client receiving erythropoietin therapy as it indicates hyperkalemia, requiring immediate intervention. High potassium levels can lead to severe cardiac arrhythmias and must be addressed promptly. The other laboratory values, though abnormal, do not present immediate life-threatening risks as hyperkalemia does.

Question 6 of 9

During the initial newborn assessment, the nurse finds that a newborn's heart rate is irregular. Which intervention should the nurse implement?

Correct Answer: C

Rationale: The correct intervention when a nurse finds an irregular heart rate in a newborn is to document the finding in the infant's record. An irregular heart rate is a common occurrence in newborns and does not necessarily require immediate medical intervention. Notifying the pediatrician immediately is unnecessary unless there are other concerning symptoms. Teaching the parents about congenital heart defects is not the priority in this situation. Applying oxygen via nasal cannula at 3 L/min is not indicated for an irregular heart rate without further assessment or medical indication.

Question 7 of 9

A client with a history of chronic heart failure is admitted with shortness of breath. Which assessment finding is most concerning?

Correct Answer: C

Rationale: Elevated liver enzymes are concerning in a client with chronic heart failure as they may indicate liver congestion or worsening heart failure, requiring immediate intervention. While crackles in the lungs and shortness of breath are common in heart failure, elevated liver enzymes specifically point towards possible liver involvement due to heart failure. A heart rate of 100 beats per minute can be expected in a client with heart failure due to compensatory mechanisms, but elevated liver enzymes signal a more severe condition.

Question 8 of 9

While assisting a male client with muscular dystrophy (MD) to the bathroom, the nurse observes that he is awkward and clumsy. When he expresses his frustration and complains of hip discomfort, which intervention should the nurse implement?

Correct Answer: A

Rationale: Placing a portable toilet next to the bed is the most appropriate intervention in this situation. It reduces the need for the client to walk long distances, thereby preventing falls and reducing discomfort. Choice B, assisting with walking exercises, would not be suitable for a client with muscular dystrophy who is experiencing awkwardness and clumsiness. Choice C, providing pain medication, may address the symptom but does not directly address the issue of reducing the need for walking. Choice D, applying a heating pad, may provide temporary relief but does not address the underlying issue of mobility and fall prevention.

Question 9 of 9

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer: A

Rationale: The correct answer is A: Watery diarrhea. This finding is the most important to report as it may indicate Clostridioides difficile infection, a severe side effect of antibiotic therapy. Clostridioides difficile infection can lead to serious complications and requires immediate medical attention. Choices B, C, and D are common side effects of linezolid but are not as critical as watery diarrhea in this context.

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