A mother runs into the emergency department with a toddler in her arms and tells the
nurse that her child got into some cleaning products. the child smells of chemicals on
the hands, face, and on the front of the child's clothes. after ensuring the airway is
patent, what action should the nurse implement first?
a. Assess the child for altered sensorium
b. Determine type of chemical exposure
c. Obtain equipment for gastric lavage
d. Call poison control emergency number
b. Determine type of chemical exposure
Which conditions are most likely to respond to treatment with antihistamines? Select
all that apply.
a. Bronchitis
b. Allergic rhinitis
c. Otitis media
d. Contact dermatitis
e. Myocarditis
b. Allergic rhinitis
d. Contact dermatitis
An older client's daughter calls the home health nurse and reports that her mother has become
forgetful and is very confused at night. The daughter states that her mother's behavior changed
suddenly a few days ago and is now getting worse. Which action should the nurse take? Select all
,that apply.
a. Ask if the mother is experiencing any pain with urination
b. Encourage increased intake of high protein foods
c. Instruct the daughter to check her mother's temperature
d. Review the client's current food and medication allergies
e. Determine if the mother has recently experienced a fall
a. Ask if the mother is experiencing any pain with urination
c. Instruct the daughter to check her mother's temperature
e. Determine if the mother has recently experienced a fall
The nurse is assessing a male with a history of Addison's disease. The client has flu-
like symptoms and nausea with vomiting over the past week. The client's spouse
reports that he acted confused and was extremely weak when he awoke this morning.
The client is febrile and has tachycardia. The health care provider diagnoses acute
adrenal insufficiency. Which medication will most likely be prescribed?
a. Hypertonic saline solution at 100 ml/hr until all edema disappears
b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg
c. Potassium chloride 20 mEq IV to infuse over 2 hours until confusion resolves
d. Regular insulin drip to keep blood glucose around 100 mg/dl (5.55 mmol/L)
b. Hydrocortisone 100 mg IV every six hours until systolic BP reaches 110 mmHg
A client with a history of mitral valve prolapse is admitted because of fever and dyspnea
on exertion, and is diagnosed with acute infective endocarditis. During the admission
assessment, the nurse observes multiple areas of petechiae on the client's skin. Which
intervention should the nurse include in the client's plan of care? Select all that apply.
,a. Monitor cardiac rhythm via telemetry
b. Report changes in pre-existing murmurs
c. Schedule rest periods between activities
d. Maintain record of fluid intake and output
e. Initiate contact transmission precautions
a. Monitor cardiac rhythm via telemetry
b. Report changes in pre-existing murmurs
e. Initiate contact transmission precautions
The nurse is planning an educational session for new parents on ways to prevent
sudden infant death syndrome (SIDS). Which information is most important to provide
parents of newborns and infants?
a. Remove pillows and soft toys from the crib at bedtime
b. Keep a bulb syringe accessible for use for an infant
c. Position the infant in a supine position while sleeping
d. Do not prop bottles for an infant during naps and bedtime
c. Position the infant in a supine position while sleeping
The healthcare provider prescribes methylergonovine maleate for a postpartum
client with uterine atony. What findings should indicate to the nurse to withhold the
next dose of medication?
a. Hypertension
b. Difficulty locating the uterine fundus
, c. Saturation of more than one pad per hour
d. Excessive lochia
a. Hypertension
The nurse notes that an older adult client has a moist cough that increases in severity
during and after meals. Based on this finding, which action should the nurse take?
a. Collect a sputum specimen immediately
b. Request a consultation to confirm dysphasia
c. Offer the client additional clear liquids frequently
d. Encourage the client to do deep breathing exercises daily
b. Request a consultation to confirm dysphasia
A multiparous client who delivered her infant 3 hours ago asks the nurse if she can
take a warm sitz bath because it helped reduce perennial pain after her last delivery.
What action should the nurse implement?
a. Using analgesic spray to the perennial area to reduce pain
b. Apply an ice pack to the perineum for the first 24 hours
c. Teach the client how to practice kegel exercises
d. Review the use of sitz bath equipment with the client
d. Review the use of sitz bath equipment with the client