Nokea
When preparing a site for venipunctures with alcohol, how long must the area be cleaned?
- A. 5 seconds
- B. 10 seconds
- C. 30 seconds
- D. 60 seconds
Correct Answer: C
Rationale: When preparing a site for venipunctures with alcohol, it is important to clean the area for at least 30 seconds. This ensures that the alcohol thoroughly disinfects the skin and reduces the risk of introducing infections during the procedure. Cleaning the area for a full 30 seconds allows the alcohol to effectively kill any bacteria present on the skin's surface, creating a safe environment for the venipuncture to take place. Shortening the cleaning time may compromise the cleanliness of the site and increase the chances of contamination. Therefore, 30 seconds is the recommended duration for cleaning the site with alcohol before a venipuncture.
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An adolescent teen has bulimia. Which assessment finding should the nurse expect to assess?
- A. Diarrhea
- B. Amenorrhea
- C. Cold intolerance
- D. Erosion of tooth enamel
Correct Answer: D
Rationale: Bulimia involves recurrent episodes of binge eating followed by compensatory behaviors such as vomiting. The frequent exposure of the teeth to stomach acid during vomiting can lead to erosion of tooth enamel. This can result in dental issues such as decay, sensitivity, and discoloration. Therefore, erosion of tooth enamel is a common assessment finding in individuals with bulimia. The other options (A. Diarrhea, B. Amenorrhea, C. Cold intolerance) are not typically associated with bulimia.
which of the following is the primary objective of care for the child with nephrosis?
- A. reduce blood pressure.
- B. reduce excretion of urinary protein.
- C. increase excretion of urinary protein.
- D. increase ability of tissues to retain fluid.
Correct Answer: B
Rationale: The primary objective of care for a child with nephrosis, also known as nephrotic syndrome, is to reduce the excretion of urinary protein. Nephrosis is a condition characterized by excessive loss of protein through the urine, leading to hypoalbuminemia and edema. By reducing the excretion of urinary protein, healthcare providers aim to minimize protein loss and improve the child's nutritional status and overall health. This can be achieved through medications such as corticosteroids, diuretics, and other treatments that help to decrease proteinuria and manage symptoms associated with nephrosis. Additionally, dietary modifications and monitoring for complications such as infection and thrombosis are important aspects of care for children with nephrosis.
.A client complains of urinary discomfort and a burning sensation while urinating. A urethral smear shows evidence of urethritis, and the client is prescribed antibiotics and instructed to drink 2-3 L of water daily. For which of the ff reasons is the client advised to drink the specified amount of water?
- A. It will help him overcome urinary incontinence
- B. It will promote renal blood flow and flush bacteria from the urinary tract
- C. It will help him eliminate urinary odors
- D. It will provide relief from pain and discomfort as a result of urinary tract infection DISTURBANCES IN FLUIDS AND ELECTROLYTES
Correct Answer: B
Rationale: The client is advised to drink 2-3 liters of water daily because it will promote renal blood flow and flush bacteria from the urinary tract. Increased water intake helps to dilute the urine, making it easier to flush out harmful bacteria that may be causing the urinary discomfort and urethritis. Adequate hydration is crucial for maintaining healthy urinary function and preventing urinary tract infections. By increasing water consumption, the client can help reduce the concentration of bacteria in the urinary tract, supporting the effectiveness of the prescribed antibiotics in treating the urethritis.
Austin, age 6 months, has six teeth. How should the nurse interpret this finding?
- A. Normal tooth eruption
- B. Delayed tooth eruption
- C. Unusual and dangerous
- D. Earlier-than-normal tooth eruption
Correct Answer: A
Rationale: The eruption of teeth in infants typically begins around 6 months of age, with the lower central incisors being the first to appear. Having six teeth at 6 months old is within the normal range of tooth eruption for infants. The average time frame for infants to have their first teeth is between 4 to 7 months, so Austin's situation falls within that range. There is no cause for concern or interpretation of the finding as unusual or dangerous in this scenario.
Which action by the nurse demonstrates use of evidence-based practice (EBP)?
- A. Gathering equipment for a procedure
- B. Documenting changes in a patient's status
- C. Questioning the use of daily central line dressing changes
- D. Clarifying a physician's prescription for morphine
Correct Answer: C
Rationale: Questioning the use of daily central line dressing changes demonstrates the use of evidence-based practice (EBP) by the nurse. In EBP, decisions about patient care should be informed by the best available evidence, clinical expertise, and patient preferences. By questioning the necessity of daily dressing changes for central lines, the nurse is seeking to ensure that the care provided is based on sound evidence and best practices rather than simply following routine procedures. This critical thinking and questioning approach aligns with the principles of evidence-based practice.