Answers Verified 100% Correct
A child in the ED who has a fever and fluid-filled vesicles on the trunk and extremities.
What intervention is priority? - ANSWER - Initiate transmission-based precautions
- This indicates that the child most likely has varicella, which is infectious
A nurse is assessing a pt for compartment syndrome. What is an expected finding? -
ANSWER - Edema
- Compartment syndrome causes increased pain, pallor, and paresthesias from
increased edema
A nurse is assessing a pt after giving epinephrine for an anaphylactic reaction. What is
an adverse effect of this medication? - ANSWER - Chest pain
- Epinephrine increases cardiac workload and oxygen demand, which can result in
angina
A nurse is providing teaching to a pt who is 24wks gestation and is scheduled for a 3hr
oral glucose tolerance test. Which of the following instructions should the nurse include?
- ANSWER - You will need to fast the night before the test
A nurse is assessing an older adult pt with pneumonia. Which finding should the nurse
expect? - ANSWER - Acute confusion
- Typical findings in an older adult is acute confusion, fatigue, lethargy, and anorexia
A pt in the ED has been having nausea and vomiting for the past 2days. What finding
should be expected? - ANSWER - Urine specific gravity of 1.052, this indicates
dehydration
- Normal urine specific gravity is 1.002-1.030
A nurse is caring for a post-op pt who received moderate (conscious) sedation. The pt
suddenly becomes restless and reports feeling lightheaded. What actions is priority? -
ANSWER - Check the O2 saturation
, - Restlessness and lightheadedness are indications of hypoxia
A nurse is providing teaching to a pt newly diagnosed with type 1 diabetes. The nurse
should instruct the pt to monitor for which finding as a sign of hypoglycemia? -
ANSWER - Irritability
A pt with a DVT should be told to do what? - ANSWER - Instruct the pt to elevate the
affected extremity when sitting
- This reduces edema and helps with venous return
A nurse is providing information to a pt before their scheduled Romberg test. What
information should be said? - ANSWER - The test will occur once with your eyes open
and once with them closed
- This test assesses balance and motor function
A nurse is providing teaching for a parent of a child with autism disorder. Which
instructions should be given? - ANSWER - Use a reward system to modify the child's
behavior
- These children respond well to reward systems, which can provide structure and
expectations for behavior
A nurse is providing teaching to a pt who is to receive electroconvulsive therapy (ECT).
The nurse should inform the pt that what finding is an adverse effect? - ANSWER -
Short term memory loss
- This is a common adverse effect
A pt has been prescribe chlorpromazine. What finding is an indication that the
medication is effective? - ANSWER - Decreased hallucinations
- This is an antipsychotic medication
A nurse is developing a discharge plan for a shool-age shild with thrombocytopenia.
The nurse should instruct the child to avoid which of the following? - ANSWER -
Blowing the nose
- This increases the child's risk for bleeding or hemorrhaging