GCC 776 - 800

Following eruption of the primary teeth, the mother can promote chewing by giving the toddler:

• Pieces of hot dog
• Celery sticks
• Melba toast
• Grapes
• -

Answer explanation

Option A: Pieces of hot dog

Option B: Celery sticks

Option C: Melba toast

Option D: Grapes

Option E: -

Correct Option: Option C – Melba toast

Explanation: Melba toast promotes chewing and is easily managed by the toddler. Pieces of hot dog, celery sticks, and grapes are unsuitable for the toddler because of the risk of aspiration.

A client with a femur fracture is exhibiting shortness of breath, pain upon deep breathing, and a cough that produces blood-tinged sputum. The nurse would determine that these clinical manifestations are indicative of which of the following?

• Congestive heart failure
• Pulmonary embolus
• Adult respiratory distress syndrome
• Tension pneumothorax
• -

Answer explanation

Option A: Congestive heart failure

Option B: Pulmonary embolus

Option C: Adult respiratory distress syndrome

Option D: Tension pneumothorax

Option E: -

Correct Option: Option B – Pulmonary embolus

Explanation: Hemoptysis is a hallmark symptom of a pulmonary embolus. This client's fracture history and other clinical manifestation leads to this conclusion. The clinical manifestations as a group do not correlate with the diagnoses in answers A, C, and D.

During discharge teaching, which instruction should the nurse give to a patient diagnosed with pancreatitis?

• Consume high-fat meals.
• Consume low-calorie meals.
• Limit daily alcohol intake.
• Avoid foods and beverages that contain caffeine.
• -

Answer explanation

Option A: Consume high-fat meals.

Option B: Consume low-calorie meals.

Option C: Limit daily alcohol intake.

Option D: Avoid foods and beverages that contain caffeine.

Option E: -

Correct Option: Option D – Avoid foods and beverages that contain caffeine.

Explanation: A patient with pancreatitis should avoid foods and beverages that can cause a relapse of the disease, including caffeine, which is a stimulant that will further irritate the pancreas. The patient should avoid all alcohol, not just limit his intake (Option C), because chronic alcohol use is one of the causes of pancreatitis. The patient should maintain a diet low in fats and high in calories, especially carbohydrates, not high in fats (Option A) or low in calories (Option B).

A night shift nurse receives shift report from the day shift nurse when the day nurse states, "I have an appointment and I need to leave. Can you get the rest of the clients' information from the medical records?" Which client right is violated by the day nurse?

• The clients' right to reasonable continuity of care.
• The clients' right to confidentiality.
• The clients' right to considerate and respectful care.
• The clients' right to make decisions about the plan of care and proposed treatment.
• -

Answer explanation

Option A: The clients' right to reasonable continuity of care.

Option B: The clients' right to confidentiality.

Option C: The clients' right to considerate and respectful care.

Option D: The clients' right to make decisions about the plan of care and proposed treatment.

Option E: -

Correct Option: Option A – The clients' right to reasonable continuity of care.

Explanation: An incomplete or uninformative client report from one health care provider to the next violates the client's right to reasonable continuity of care. The client's right to confidentiality is not violated because both nurses have been assigned to care for the client. Information pertaining to client care is passed between health care providers during care reports to safeguard continuity of care. The right to considerate and respectful care and the right to make decisions about the plan of care are not addressed in this scenario, so these answer options are incorrect.

The nurse caring for a client with anemia recognizes which clinical manifestation as the one that is specific for a hemolytic type of anemia?

• Jaundice
• Anorexia
• Tachycardia
• Fatigue
• -

Answer explanation

Option A: Jaundice

Option B: Anorexia

Option C: Tachycardia

Option D: Fatigue

Option E: -

Correct Option: Option A – Jaundice

Explanation: In hemolytic anemia, destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with several anemias, but they are not specific to hemolytic. Answer B does not relate to anemia.

The nurse is ready to begin an exam on a 9-month-old infant. The child is sitting in his mother's lap. What should the nurse do first?

• Check the Babinski reflex
• Listen to the heart and lung sounds
• Palpate the abdomen
• Check tympanic membranes
• -

Answer explanation

Option A: Check the Babinski reflex

Option B: Listen to the heart and lung sounds

Option C: Palpate the abdomen

Option D: Check tympanic membranes

Option E: -

Correct Option: Option B – Listen to the heart and lung sounds

Explanation: The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child's ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect.

A patient, age 23, underwent a rhinoplasty 6 hours ago. After administering his pain medication, the nurse notes that he is swallowing frequently. What is the most likely cause of the swallowing?

• Oral dryness caused by nasal packing
• Bleeding posterior to the nasal packing
• An adverse reaction to the analgesic
• A normal response to the analgesic
• -

Answer explanation

Option A: Oral dryness caused by nasal packing

Option B: Bleeding posterior to the nasal packing

Option C: An adverse reaction to the analgesic

Option D: A normal response to the analgesic

Option E: -

Correct Option: Option B – Bleeding posterior to the nasal packing

Explanation: In a patient who has nasal packing in place, frequent swallowing may indicate bleeding in the posterior pharynx. Option A is incorrect because mouth dryness causes thirst, not frequent swallowing. Options C and D are incorrect because frequent swallowing isn't a response to analgesics.

An infant with respiratory syncytial virus has been started on Virazole (ribavirin). When caring for the infant receiving Virazole, the nurse should:

• Discontinue isolation precautions while the medication is being administered
• Use contact precautions only when opening the mist tent
• Temporarily stop administration of the medication when the mist tent needs to be opened
• Increase the rate of medication administration when the mist tent needs to be opened
• -

Answer explanation

Option A: Discontinue isolation precautions while the medication is being administered

Option B: Use contact precautions only when opening the mist tent

Option C: Temporarily stop administration of the medication when the mist tent needs to be opened

Option D: Increase the rate of medication administration when the mist tent needs to be opened

Option E: -

Correct Option: Option C – Temporarily stop administration of the medication when the mist tent needs to be opened

Explanation: The nurse should temporarily stop the administration of the Virazole when the mist tent needs to be opened to allow the medication particles to settle. Answer A is incorrect because contact precautions should be used even though the infant is receiving Virazole. Answer B is incorrect because contact precautions are used whether the mist tent is opened or closed. Answer D is incorrect because increasing or decreasing the rate of medication administration is not a nursing function.

During the first few days of recovery from ostomy surgery for ulcerative colitis, which aspect of patient care should take priority?

• Body image
• Ostomy care
• Sexual concerns
• Skin care
• -

Answer explanation

Option A: Body image

Option B: Ostomy care

Option C: Sexual concerns

Option D: Skin care

Option E: -

Correct Option: Option B – Ostomy care

Explanation: Although the nurse should address body image (Option A), sexual concerns (Option C), and skin care (Option D) as needed, ostomy care—including the crucial task of helping the patient learn to safely manage the ostomy before discharge—takes priority.

The nurse is aware that the best way to prevent post-operative wound infection in the surgical client is to:

• Administer a prescribed antibiotic
• Wash her hands for 2 minutes before care
• Wear a mask when providing care
• Ask the client to cover her mouth when she coughs
• -

Answer explanation

Option A: Administer a prescribed antibiotic

Option B: Wash her hands for 2 minutes before care

Option C: Wear a mask when providing care

Option D: Ask the client to cover her mouth when she coughs

Option E: -

Correct Option: Option B – Wash her hands for 2 minutes before care

Explanation: The best way to prevent post-operative wound infection is handwashing. Use of prescribed antibiotics will treat infection, not prevent infections, so answer A is incorrect. Wearing a mask and asking the client to cover her mouth are good practices but will not prevent wound infections; thus, answers C and D are incorrect.