The nurse knows that which statement by the
mother indicates that the mother understands
safety precautions with her four month-old
infant and her 4 year-old child?
A) “I strap the infant car seat on the front seat to
face backwards.”
B) “I place my infant in the middle of the living
room floor on a blanket to play with my
4 year old while I make supper in the kitchen.”
C) “My sleeping baby lies so cute in the crib with
the little buttocks stuck up in the air while the four
year old naps on the sofa.”
D) “I have the 4 year-old hold and help feed the
four month-old a bottle in the kitchen
while I make supper.” – ANSWER-is D: “I have the
four year-old hold and help feed the four month-old
a bottle in the kitchen
Upon completing the admission documents, the
nurse learns that the 87 year-old client does not
have an advance directive. What action should
the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary – ANSWERis
B: Give information about advance directives
A nurse administers the influenza vaccine to a client
in a clinic. Within 15 minutes after
the immunization was given, the client complains of
itchy and watery eyes, increased
anxiety, and difficulty breathing. The nurse expects
that the first action in the sequence of care for this
client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered –
ANSWER-is B: Administer epinephrine 1:1000 as
ordered .
