A 6-year-old child who has chickenpox also
has a fever of 102.9° F (39.4° C). The child's mother asks the nurse if she should use aspirin to reduce the fever. What is the best response by the nurse?
a. "It's best to wait to see if the fever gets worse."
b. "You can use the aspirin, but watch for worsening symptoms."
c. "Acetaminophen (Tylenol) should be used to reduce his fever, not aspirin."
d. "You can use aspirin, but be sure to follow the instructions on the bottle."
ANS: C
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The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should:
a. reassess the patient in an hour. b. raise the arm above the level of the patient's heart. c. notify the provider immediately. d. apply warm packs to the fistula site and reassess.
A nurse completes the admission assessment of an 84-year-old client to the long-term care facility. Which assessment finding would direct the nurse to document a deficit in the client's ADLs?
A) The client experiences chronic pain as a result of rheumatoid arthritis. B) The client is able to ambulate with a wheeled walker for 60 ft but then requires a rest break. C) The client is able to wash self but requires assistance entering and leaving the bathtub. D) The client is unable to explain the rationale for each of the prescribed medications.
A nurse receives a report on a patient who just returned from surgery following a transurethral prostatectomy. The nurse is told that the patient has a urinary catheter. The nurse will most likely find
1. A suprapubic catheter. 2. A three-way catheter. 3. A condom catheter. 4. A coudé catheter.
During a school physical examination, the nurse reviews the patient's current medical history. The nurse discovers the patient has allergies. Which assessment finding is consistent with allergies?
a. Clubbing b. Yellow discharge c. Pale nasal mucosa d. Puffiness of nasal mucosa