A 12-month old boy is admitted with a respiratory infection and possible pneumonia. He is
placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for
this infant?
A. give small, frequent feedings of fluids
B. accurately chart observations regarding breath sounds
C. have a bulb syringe readily available to remove secretions
D. encourage older siblings to visit - CORRECT ANSWER - C. have a bulb syringe readily
available to remove secretions
A patient airway has the highest priority. Humidification will liquefy the nasal secretions
thereby increasing the amount of secretions and making (C) the highest priority. (A)
,maintains hydration and prevents, but an open airway has the highest priority. (B) is
important for evaluations of therapy. When asked "priority" questions, remember Maslow.
Physical needs usually have a higher priority than psychosocial needs. An open airway is the
highest physiological need
a 14-year old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
A. Remove all blackheads and follow with an alcohol scrub
B. Use medicated cosmetics only to help hide the blemishes.
C. Wash the hair and skin frequently with soap and hot water.
D. Encourage her to see a dermatologist as soon as possible. - CORRECT ANSWER - C.
Wash the hair and skin frequently with soap and hot water
Washing the hair and skin with soap and hot water removes oil and debris from the skin and
helps prevent and treat acne. Oily skin is especially bothersome during adolescence when
,hormones cause enlargement of sebaceous glands and increased glandular secretions which
predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not)
should be used sparingly to avoid further blocking of sebaceous gland ducts. (D) may be
indicated at a later time, if healthcare recommendations are not successful.
A 15 year old girl tells the school nurse that all of her friends have started their periods and
she feels abnormal because she has not. Which response is best for the nurse to provide?
A. refer the adolescent to the healthcare provider for a pregnancy screen
B. schedule a conference with her parents to recommend hormone therapy
C. explain that menarche varies and occurs between the ages of 12 and 18 years.
D. suggest that she use diversions to help her not worry about delayed menarche -
CORRECT ANSWER - C. explain that menarche varies and occurs between the ages of 12 and
18 years.
, The nurse should provide a factual and reassuring explanation that focuses on individual
variations of menarche, which can normally occur between 12 and 18 years of age. (A) does
not address the adolescent's concern and is judgmental. Menarche is influenced by
hereditary general health and nutritional status, so (B) is not indicated. (D) dismisses the
adolescent's concerns and does not offer factual information.
A 16 year old is brought to the emergency department with a crushed leg after falling off a
horse. the adolescent's last tetanus toxoid booster was received eight year ago. What action
should the nurse take?
A. dispense a tetanus antitoxin
B. prepare human tetanus immune globulin
C. administer tetanus toxoid booster
D. delay the tetanus toxoid booster until due - CORRECT ANSWER - C. administer tetanus
toxoid booster
placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for
this infant?
A. give small, frequent feedings of fluids
B. accurately chart observations regarding breath sounds
C. have a bulb syringe readily available to remove secretions
D. encourage older siblings to visit - CORRECT ANSWER - C. have a bulb syringe readily
available to remove secretions
A patient airway has the highest priority. Humidification will liquefy the nasal secretions
thereby increasing the amount of secretions and making (C) the highest priority. (A)
,maintains hydration and prevents, but an open airway has the highest priority. (B) is
important for evaluations of therapy. When asked "priority" questions, remember Maslow.
Physical needs usually have a higher priority than psychosocial needs. An open airway is the
highest physiological need
a 14-year old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
A. Remove all blackheads and follow with an alcohol scrub
B. Use medicated cosmetics only to help hide the blemishes.
C. Wash the hair and skin frequently with soap and hot water.
D. Encourage her to see a dermatologist as soon as possible. - CORRECT ANSWER - C.
Wash the hair and skin frequently with soap and hot water
Washing the hair and skin with soap and hot water removes oil and debris from the skin and
helps prevent and treat acne. Oily skin is especially bothersome during adolescence when
,hormones cause enlargement of sebaceous glands and increased glandular secretions which
predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not)
should be used sparingly to avoid further blocking of sebaceous gland ducts. (D) may be
indicated at a later time, if healthcare recommendations are not successful.
A 15 year old girl tells the school nurse that all of her friends have started their periods and
she feels abnormal because she has not. Which response is best for the nurse to provide?
A. refer the adolescent to the healthcare provider for a pregnancy screen
B. schedule a conference with her parents to recommend hormone therapy
C. explain that menarche varies and occurs between the ages of 12 and 18 years.
D. suggest that she use diversions to help her not worry about delayed menarche -
CORRECT ANSWER - C. explain that menarche varies and occurs between the ages of 12 and
18 years.
, The nurse should provide a factual and reassuring explanation that focuses on individual
variations of menarche, which can normally occur between 12 and 18 years of age. (A) does
not address the adolescent's concern and is judgmental. Menarche is influenced by
hereditary general health and nutritional status, so (B) is not indicated. (D) dismisses the
adolescent's concerns and does not offer factual information.
A 16 year old is brought to the emergency department with a crushed leg after falling off a
horse. the adolescent's last tetanus toxoid booster was received eight year ago. What action
should the nurse take?
A. dispense a tetanus antitoxin
B. prepare human tetanus immune globulin
C. administer tetanus toxoid booster
D. delay the tetanus toxoid booster until due - CORRECT ANSWER - C. administer tetanus
toxoid booster
