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The clinic nurse is taking the vital signs of a 1-year-old. Which finding
should the nurse bring to the attention of the healthcare provider?
A.
Temperature: 97.5°F/36.4°C
B.
Pulse: 80 beats/min
C.
Respirations: 26 breaths/min
D.
Blood pressure: 90/53 mm Hg -ANSWERS-B
Rationale: A normal pulse rate for a 1-year-old is 90 to 130. This child's
heart beat is below the normal range. The remaining vital signs are
within the normal limits for a 1-year-old.
The clinic nurse is reviewing an antibiotic medication prescribed to a
client with a urinary tract infection. What instructions will the nurse
include in the client's teaching? (Select all that apply.)
A.
,Take all of the medication as prescribed, especially when you start
feeling better.
B.
Take the medication with 8 ounce/240 mL of water.
C.
Call poison control if you start itching, develop hives, or have difficulty
breathing.
D.
Keep this medication out of the reach of small children, preferably in a
locked cabinet.
E.
Call your healthcare provider (HCP) when your symptoms subside. -
ANSWERS-A, B, D
Rationale: Once symptoms subside, it is sometime hard to remember to
take antibiotics. The client needs to take the full course of antibiotics to
achieve the maximum effect. Drinking a glass of water will help keep
the body hydrated. All medication should be kept out of reach,
preferably in a locked cabinet. The client needs to call the health care
provider in the event of an allergic reaction to the antibiotic. The
medication is prescribed to treat the infection. There is no need to
notify the HCP when the medication is having the desired effects.
The nurse is aware that malnutrition is a common problem among
clients served by a community health clinic for the homeless. Which
laboratory value is the most reliable indicator of chronic protein
malnutrition?
,A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level -ANSWERS-A
Rationale: Long-term protein deficiency is required to cause
significantly lowered serum albumin levels. Albumin is made by the
liver only when adequate amounts of amino acids (from protein
breakdown) are available. Albumin has a long half-life, so acute protein
loss does not significantly alter serum levels. Option B is a serum
protein with a half-life of only 8 to 10 days, so it will drop with an acute
protein deficiency. Options C and D are not clinical measures of protein
malnutrition.
A client's blood pressure reading is 156/94 mm Hg. Which action should
the nurse take first?
A.
Tell the client that the blood pressure is high and that the reading
needs to be verified by another nurse.
B.
Contact the health care provider to report the reading and obtain a
prescription for an antihypertensive medication.
, C.
Replace the cuff with a larger one to ensure an ample fit for the client
to increase arm comfort.
D.
Compare the current reading with the client's previously documented
blood pressure readings. -ANSWERS-D
Rationale: Comparing this reading with previous readings will provide
information about what is normal for this client; this action should be
taken first. Option A might unnecessarily alarm the client. Option B is
premature. Further assessment is needed to determine if the reading is
abnormal for this client. Option C could falsely decrease the reading
and is not the correct procedure for obtaining a blood pressure reading.
The nurse comes upon an automobile accident involving many cars.
Which victim should the nurse see first?
A.
The victim who is not breathing and does not have a pulse
B.
The victim who is bleeding out of both the ears, and the nose and
mouth, with a blank stare
C.
The victim who is heavily bleeding bright red blood from a thigh wound
D.
The victim who is crying, complaining of arm pain, and no other
apparent injuries -ANSWERS-C