Practice Exam Flashcards

An 8-year-old admitted with an upper-respiratory infection has an order for O2 saturation via pulse oximeter. To ensure an accurate reading, the nurse should:

Answer: Place the probe on the child’s finger

For an accurate pulse oximetry reading, the probe needs to be placed on a site with good capillary blood flow and minimal movement. In an 8-year-old child, a finger is a common and reliable site for probe placement, ensuring proper signal detection and an accurate measurement of oxygen saturation.

An infant with Tetralogy of Fallot is discharged with a prescription for lanoxin elixir. The nurse should instruct the mother to:

Answer: Administer the medication using the calibrated dropper in the bottle

Digoxin elixir is a potent medication, and precise dosing is critical, especially for infants, to avoid serious adverse effects or ineffective treatment. Using the calibrated dropper provided with the medication ensures the most accurate measurement of the prescribed dose, which is essential for patient safety and therapeutic efficacy.

The client scheduled for electroconvulsive therapy tells the nurse, “I’m so afraid. What will happen to me during the treatment?” Which of the following statements is most therapeutic for the nurse to make?

Answer: “You will be given medicine to relax you during the treatment.”

When a client expresses fear about a procedure, the most therapeutic response is to provide reassurance and clear, concise information about what they will experience. Informing the client that they will receive medication to relax them directly addresses their anxiety and offers comfort, helping to alleviate their fear without overwhelming them with medical details.

Which of the following skin lesions is associated with Lyme’s disease?

Answer: Bull’s eye rash

The classic skin lesion associated with Lyme disease is erythema migrans, which is often described as a 'bull's eye rash.' This distinctive, expanding red rash typically appears at the site of the tick bite days to weeks after exposure and is a key diagnostic indicator of the disease.

Which of the following snacks would be suitable for the child with gluten-induced enteropathy?

Answer: Buttered popcorn

Gluten-induced enteropathy, also known as celiac disease, requires a strict gluten-free diet, meaning the elimination of foods containing wheat, barley, and rye. Buttered popcorn is made from corn, which is naturally gluten-free, making it a suitable and safe snack choice for a child with this condition.

A client with schizophrenia is receiving chlorpromazine (Thorazine) 400mg twice a day. An adverse side effect of the medication is:

Answer: Elevated temperature

Chlorpromazine (Thorazine) is a first-generation antipsychotic medication. A serious, though rare, adverse effect associated with this class of drugs is Neuroleptic Malignant Syndrome (NMS), which can manifest with symptoms such as elevated temperature (hyperpyrexia), muscle rigidity, altered mental status, and autonomic dysfunction. Therefore, an elevated temperature is a critical finding requiring immediate attention.

Which information should be given to the client taking phenytoin (Dilantin)?

Answer: More frequent dental appointments will be needed for special gum care.

Phenytoin (Dilantin) is an anticonvulsant medication known to cause gingival hyperplasia, an overgrowth of gum tissue, as a common side effect with long-term use. Clients taking phenytoin need to be educated about meticulous oral hygiene practices and the importance of more frequent dental appointments for specialized gum care to manage and prevent this condition.