DETAILED QUESTIONS GRADED A+
⫸ The nurse is assessing pain after surgery in a 3 year old client with
a known developmental delay. Which pain scale should the nurse use
to assess this client's pain level?
a. CRIES scale
b. numeric scale
c. FLACC scale
d. FACES scale. Answer: c. FLACC scale
Rationale: The FLACC scale can be used for pediatric clients from
age 2 months to 7 years and is appropriate when clients cannot
communicate their pain
⫸ A client recently diagnosed with diabetes is sent home with a
prescription for subcutaneous insulin. What statement made by the
client indicates that teaching has been effective regarding safe needle
disposal?
a. "I should wrap the needle in a paper towel and place in the trash."
b. "I should use a hospital issued biohazard container for all needles."
c. "I may use any hard plastic container with a screw-on cap."
,d. "I should take my needles to the nearest hospital for disposal.".
Answer: c. "I may use any hard plastic container with a screw-on
cap."
Rationale: At home, an FDA approved sharps container is not needed,
however, needles, syringes, and sharps may be disposed of in a hard
plastic container. Clients should follow their community guidelines
for sharps container disposal. This protects the sanitation engineers
from injury by the sharps.
⫸ The primary healthcare provider suspects the client has
tuberculosis (TB) and prescribes a Mantoux test. What precautions
should the nurse take when administering the Mantoux test?
a. don sterile gloves
b. place the client on reverse isolation
c. wear a particulate respirator
d. obtain a consent form
e. initiate airborne precautions. Answer: c. wear a particulate
respirator
e. initiate airborne precautions
Rationale: A disposable particulate respirator that fits snugly around
the face is needed. The client needs to be on acid-fast bacilli (AFB)
isolation precautions, not reverse isolation. Airborne precautions
include a private room with negative pressure and a minimum of 6 air
,exchanges per hour. Ultraviolet lamps and high efficiency particulate
air filters are also needed.
⫸ A hysterical college student arrives in the emergency department in
bloody soiled clothing. The nursing assessment reveals facial bruising
and multiple contusions consistent with the client's report of being
raped. Which initial nursing intervention takes priority at this time?
a. notify police of the alleged rape
b. allow the client privacy to wash self
c. remove clothing and bag for evidence
d. encourage client to express fears and anxiety. Answer: d. encourage
client to express fears and anxiety
Rationale: Although there are specific protocols that must be followed
when dealing with rape clients, it is important to remember that this
client had all control taken away during the attack. The emotional
effects of rape are as traumatizing as the physical injuries. Allowing
the client to first express emotions, such as fear or anxiety, returns a
small amount of control to a situation in which the client has little or
none.
⫸ The nurse is caring for an adolescent client diagnosed with
depression. The client is prescribed fluoxetine. What is the best
response by the nurse when the client says, "What will this medicine
do to me?"
, a. it will increase the level of serotonin in the brain
b. it will decrease the production of noradrenaline
c. it will lower your level of the brain hormone norepinephrine
d. it will balance blood glucose and dopamine levels in your head.
Answer: a. it will increase the level of serotonin in the brain
Rationale: The action of fluoxetine is to increase the level of serotonin
in the central nervous system. There is a correlation between a low
level of serotonin and depression. The action of the drug should be
explained to the adolescent in a manner that will be understood.
⫸ A new mother brings her infant to the clinic for a well-baby
checkup. While at the clinic, the mother asks the nurse if there are any
reasons why her infant should not have the MMR vaccine. The nurse's
response is based on evidence that the MMR vaccine is
contraindicated under which condition?
a. a known allergy to gelatin
b. a family history of autism
c. in infants with diarrhea
d. a known allergy to sulfonamides. Answer: a. a known allergy to
gelatin
Rationale: The MMR vaccine is grown using chicken embryos and
manufactured with the use of gelatin. Known allergies to gelatin
would be a contraindication for administration.