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1. After the diagnosis and initial treatment of a 3-year-old with Cystic fibrosis, the nurse provides home care instructions to the mother. Which statement by the child's mother indicates that she understands home care treatment to promote pulmonary functions?
- A. Chest physiotherapy should be performed twice a day before a meal
- B. Energy should be conserved by scheduling minimally strenuous activities
- C. Administer a cough suppressant every 8 hours
- D. Maintain supplemental oxygen at 4 to 6 L/minute
Correct answer: A
Rationale: The correct answer is A. Chest physiotherapy is essential for maintaining pulmonary function in cystic fibrosis. It should be performed regularly, often twice daily, to clear mucus from the lungs. Choice B is incorrect because conserving energy does not directly promote pulmonary function. Choice C is incorrect as cough suppressants are not typically used to promote pulmonary function in cystic fibrosis. Choice D is incorrect as maintaining supplemental oxygen at 4 to 6 L/minute is not a standard home care treatment for promoting pulmonary functions in cystic fibrosis.
2. An 8-year-old child who weighs 60 pounds receives an order for Polycilin (Ampicillin) suspension 25 mg/kg/day divided into a dose every 8 hours. The medication is labeled '125 mg/5 ml'. How many ml should the nurse administer per dose every 8 hours?
- A. 5
- B. 10
- C. 15
- D. 20
Correct answer: A
Rationale: Calculate the daily dose first: 60 pounds x 25 mg/kg = 1500 mg/day. Divide by 3 doses = 500 mg/dose. Convert to mL: (500 mg / 125 mg) x 5 ml = 20 ml. However, the question asks for the dose per administration every 8 hours, which is 1/3 of the daily dose. So, the correct calculation should be (20 ml / 3) = 6.67 ml, which rounds to 5 ml. Therefore, the correct answer is 5 ml. Choice B (10 ml) is incorrect because it doesn't consider the frequency of dosing. Choice C (15 ml) is incorrect as it overestimates the dose. Choice D (20 ml) is incorrect as it represents the total daily dose, not the dose per administration every 8 hours.
3. The nurse is conducting intake interviews of children at a city clinic. Which child is most susceptible to contracting lead poisoning?
- A. An adolescent who works part-time in a paint factory
- B. A 2-year-old who plays on aging outdoor playground equipment
- C. A 10-year-old who has Type 1 diabetes mellitus
- D. An 8-year-old who lives in a housing project
Correct answer: B
Rationale: Children playing on aging playground equipment are at higher risk of lead poisoning due to potential exposure from old paint. This is because deteriorating paint on older playground equipment may contain lead, which can be ingested by young children. Choices A, C, and D do not directly involve potential exposure to lead paint, making them less susceptible to lead poisoning compared to a child playing on aging playground equipment.
4. In what order should the unit manager implement interventions to address the UAP’s behavior after they leave the unit without notifying the staff?
- A. Note date and time of the behavior.
- B. Discuss the issue privately with the UAP.
- C. Plan for scheduled break times.
- D. Evaluate the UAP for signs of improvement.
Correct answer: A
Rationale: The correct order for the unit manager to implement interventions to address the UAP's behavior is to first note the date and time of the behavior. Proper documentation is crucial as it provides a factual record of the incident. This documentation can be used to address the behavior effectively and to track any patterns or improvements in the future. Discussing the issue with the UAP privately (choice B) should come after documenting the behavior. Planning for scheduled break times (choice C) is unrelated to the situation described and does not address the UAP's behavior of leaving without notifying the staff. Evaluating the UAP for signs of improvement (choice D) can only be done effectively after the behavior has been addressed and interventions have been implemented.
5. The healthcare provider receives a report on four clients who are complaining of increased pain. Which client requires immediate attention by the healthcare provider?
- A. Burning pain due to a Morton’s neuroma
- B. Sharp pain related to a crushed femur
- C. Paresthesia of fingers due to carpal tunnel syndrome
- D. Stinging pain related to plantar fasciitis
Correct answer: B
Rationale: Sharp pain related to a crushed femur indicates a severe condition and potential serious complications that require immediate attention. Crushed femur can lead to severe bleeding, nerve damage, or compartment syndrome, which are critical and life-threatening. The other choices, although painful, are less likely to present immediate life-threatening issues. Morton’s neuroma, carpal tunnel syndrome, and plantar fasciitis are painful conditions but are not typically associated with urgent, life-threatening complications like a crushed femur.
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