A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expect to find? A. Open anterior and fontanel and closed posterior fontanel B. Closed anterior and posterior fontanels C. Closed anterior fontanel and open posterior fontanel D.… Read More »
A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which of the following nursing measures should the nurse do first? A. Assess vital signs B. Institute seizure precautions C. Assess neurologic status D. Place in respiratory isolation Correct Answer: D. Place in… Read More »
A client who has recently traveled to China comes to the emergency department (ED) with increasing shortness of breath and is strongly suspected of having a severe acute respiratory syndrome (SARS). Which of these prescribed actions will you take first? A. Obtain blood, urine, and sputum for cultures B. Infuse normal saline at 100ml/hr… Read More »
Patrick, a healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client’s fluid intake because fluid overload may cause: A. Dehydration B. Hypovolemic shock C. Cerebral edema D. Heart failure Correct Answer: C. Cerebral edema Due to the inflammation of… Read More »
A client is diagnosed with methicillin-resistant staphylococcus aureus pneumonia. What type of isolation is most appropriate for this client? A. Reverse isolation B. Respiratory isolation C. Contact isolation D. Standard precautions Correct Answer: C. Contact isolation Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g.… Read More »
Four clients with infections arrive at the emergency department with some existing infection, however, only one private room is available. Which of the following clients is the most appropriate to assign to the private room? A. A client with toxic shock syndrome and a temperature of 102.4°F (39.1°C). B. A client with diarrhea caused by… Read More »
An infant is hospitalized for treatment of nonorganic failure to thrive. Which nursing action is most appropriate for this infant? A. Encouraging the infant to hold a bottle B. Keeping the infant on bed rest to conserve energy C. Rotating caregivers to provide more stimulation D. Maintaining a consistent, structured environment … Read More »
Several clients are admitted to an adult medical unit. The nurse would ensure airborne precautions for a client with which of the following medical conditions? A. A diagnosis of AIDS and cytomegalovirus B. A positive PPD with an abnormal chest x-ray C. A tentative diagnosis of viral pneumonia D. Mycoplasma pneumonia… Read More »
You are caring for four clients who are receiving IV infusions of normal saline. Which client is at the highest risk for bloodstream infections? A. A client who has nontunneled central line in the left internal jugular vein. B. A client with an implanted port in the right subclavian vein. C. A client with… Read More »
The mother of Gian, a preschooler with spina bifida tells the nurse that her daughter sneezes and gets a rash when playing with brightly colored balloons, and that she recently had an allergic reaction after eating kiwifruit and bananas. The nurse would suspect that the child may have an allergy to: A. Bananas … Read More »