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1. When evaluating a kinetic family drawing, which of the following nursing actions is most effective?
- A. instructing the child to draw their family doing something
- B. suggesting specific elements to include in the drawing
- C. discouraging the child from discussing the drawing
- D. noting the omission of any family members
Correct answer: noting the omission of any family members
Rationale: When evaluating a kinetic family drawing, the most effective nursing action is noting the omission of any family members. This approach helps healthcare providers gather crucial information about family dynamics. It is important to pay attention to what the child includes and omits in the drawing, as it can provide insights into underlying emotions and concerns. Choices A, B, and C are not recommended actions for evaluating the drawing. Instructing the child to draw their family doing something or suggesting specific elements to include may bias the drawing, leading to misinterpretations. Discouraging the child from discussing the drawing can impede communication and the understanding of the child's perspective.
2. A client with acute leukemia develops a low white blood cell count. In addition to the institution of isolation, the nurse should:
- A. Request that foods be provided in sealed single-serving packages
- B. Ask the client to wear a mask when visitors are present
- C. Prep IV sites with mild soap and water and alcohol
- D. Provide foods in sealed single-serving packages
Correct answer: Provide foods in sealed single-serving packages
Rationale: For a client with acute leukemia and a low white blood cell count, preventing exposure to food contaminants is crucial due to immune suppression. Providing foods in sealed single-serving packages helps reduce the risk of contamination. Choice B is incorrect as it introduces the potential of infection from visitors. Choice A, suggesting disposable utensils, is not as effective as sealed containers in preventing food contamination. Choice C, using alcohol for prepping IV sites, is less suitable due to its drying effect and potential for skin breakdown, making sealed packages a better option for food safety.
3. A nurse monitoring a newborn infant notes that the infant’s respirations are 40 breaths/min. On the basis of this finding, what is the most appropriate action for the nurse to take?
- A. Contacting the registered nurse
- B. Documenting the findings
- C. Wrapping an extra blanket around the infant
- D. Placing the infant in an oxygen tent
Correct answer: Documenting the findings
Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths/min, with an average of 40. Since the infant's respiratory rate falls within the normal range, the most appropriate action for the nurse is to document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, or wrapping an extra blanket around the infant are unnecessary actions as the respiratory rate is normal. Documenting the findings is important to provide a record of the assessment and serve as a baseline for future comparisons if needed.
4. When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
- A. low back pain
- B. urinary frequency
- C. GI distress
- D. malaise
Correct answer: urinary frequency
Rationale: Urinary frequency is least indicative of UTI during pregnancy. It is a common minor discomfort of pregnancy caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are usually no problems. Frequency may return in the third trimester when the uterus drops into the pelvic cavity. UTI symptoms include low back pain, suprapubic discomfort, and malaise, and are confirmed by laboratory findings. Low back pain, GI distress, and malaise are more closely associated with UTI during pregnancy compared to urinary frequency.
5. A 46-year-old has returned from a heart catheterization and wants to get up to start walking 3 hours after the procedure. The nurse should:
- A. Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
- B. Allow the patient to begin limited ambulation with assistance.
- C. Recommend a physical therapy consultation for ambulation.
- D. Tell the patient to remain with the leg straight for another 6 hours and check the chart for activity orders.
Correct answer: Tell the patient to remain with the leg straight for at least another hour and check the chart for activity orders.
Rationale: The correct answer is to tell the patient to remain with the leg straight for at least another hour after a heart catheterization before starting ambulation. This period allows for proper healing and reduces the risk of complications such as bleeding or hematoma formation at the catheter insertion site. Starting ambulation too soon can disrupt the healing process and lead to adverse events. Choice B is incorrect because limited ambulation should not be initiated shortly after the procedure as it may increase the risk of complications. Choice C is incorrect as physical therapy consultation is not typically necessary for initial ambulation post-heart catheterization; this can be managed by nursing staff. Choice D is incorrect as keeping the leg straight for 6 hours is excessive and unnecessary, potentially leading to complications such as deep vein thrombosis due to prolonged immobility.
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