a nurse working in a pediatric clinic observes bruises on the body of a four year old boy the parents report the boy fell riding his bike the bruises
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NCLEX-PN

NCLEX-PN Quizlet 2023

1. A nurse working in a pediatric clinic observes bruises on the body of a four-year-old boy. The parents report the boy fell while riding his bike. The bruises are located on his posterior chest wall and gluteal region. What should the nurse do?

Correct answer: C

Rationale: In this scenario, the nurse is observing bruises on a child's body that are located in areas not commonly associated with accidental injuries. Given the concerning nature of the bruising pattern and the inconsistent history provided by the parents, the nurse should suspect possible child abuse and take appropriate action by notifying the case manager in the clinic. The safety and well-being of the child should always be the top priority. Counseling for the family, warm baths, or recommending range of motion (ROM) exercises are not appropriate actions in this situation and may not address the underlying issue of potential child abuse.

2. A 20-year-old obese female client is preparing to have gastric bypass surgery for weight loss. She says to the nurse, 'I need this surgery because nothing else I have done has helped me to lose weight.' Which response by the nurse is most appropriate?

Correct answer: D

Rationale: The most appropriate response by the nurse is to show respect and empathy towards the client's decision. Choosing surgery for weight loss is a significant decision, and acknowledging and respecting this choice is crucial in providing patient-centered care. Option D is the correct answer as it validates the client's decision and shows support. Options A, B, and C are all inappropriate as they do not address the client's feelings, lack empathy, and can be considered insensitive and unprofessional.

3. The nurse is obtaining a health assessment from the preoperative client scheduled for hip replacement surgery. Which statement by the client would be most important for the nurse to report to the physician?

Correct answer: B

Rationale: The most important statement for the nurse to report to the physician is that the client had rheumatic fever when they were 10 years old. This information is crucial as individuals who have had rheumatic fever require pre-medication with antibiotics before any surgical or dental procedure to prevent bacterial endocarditis. Reporting this history ensures the client's safety during the hip replacement surgery. The other options, such as having chickenpox in the past, a family history of gastric cancer, or experiencing hip pain, are important for the client's overall health assessment but do not have the same immediate implications for the upcoming surgery as the history of rheumatic fever.

4. Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:

Correct answer: A

Rationale: Metformin is classified as an antihyperglycemic agent because it works by reducing hepatic glucose output and decreasing glucose absorption from the gut, thereby preventing hyperglycemia. Choice B, a hypoglycemic agent, is incorrect as hypoglycemic agents stimulate insulin production, which is not the mechanism of action of metformin. Choice C, an insulin analogue, is incorrect as metformin is not a type of insulin but a distinct medication. Choice D, a pancreatic alpha cell stimulant, is incorrect as metformin does not stimulate any pancreatic cells, but rather acts on the liver and gut to lower blood sugar levels.

5. When preparing a client for platelet pheresis in the blood bank, which information is most significant to obtain during the history assessment?

Correct answer: B

Rationale: The most significant information to gather when a client is scheduled for platelet pheresis is the date of their last platelet donation. Platelet donors can typically have their platelets apheresed as frequently as every 14 days. Knowing the date of the last donation helps ensure the client is eligible for the procedure without risking any adverse effects from frequent donations. Allergies to shellfish may be important for other procedures where anticoagulants containing heparin are used, but it is not directly related to platelet pheresis. The time of the last oral intake is more crucial for procedures requiring sedation or anesthesia. Blood type is significant for blood transfusions but is not the primary concern for platelet pheresis.

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