Nokea
The nurse teaching an older client about general hygienic measures for foot and nail care should include which instructions? Select all that apply.
- A. Wear knee-high hose to prevent edema.
- B. Soak and wash the feet daily using cool water.
- C. Use commercial removers for corns or calluses.
- D. Use over-the-counter preparations to treat ingrown nails.
- E. Apply lanolin or baby oil if dryness is noted along the feet.
- F. Pat the feet dry thoroughly after washing and dry well between toes.
Correct Answer: E,F
Rationale: The nurse should offer the following guidelines in a general hygienic foot and nail care program: Inspect the feet daily, including the tops and soles of the feet, the heels, and the areas between the toes; wash the feet daily using lukewarm water, and avoid soaks to the feet, thoroughly patting the feet dry and drying well between toes; and avoid cutting corns or calluses or using commercial removers. Additional general hygienic measures include gently rubbing lanolin, baby oil, or corn oil into the skin if dryness is noted along the feet or between the toes; filing the toe nails straight across and square (do not use scissors or clippers); avoiding the use of over-the-counter preparations to treat ingrown toenails and consulting a primary health care provider for these problems; and avoiding wearing elastic stockings (unless prescribed by a health care professional), knee-high hose, or constricting garters.
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The nurse is assigned to care for an infant on the first postoperative day after a surgical repair of a cleft lip. Which nursing intervention is appropriate when caring for this child's surgical incision?
- A. Rinsing the incision with sterile water after feeding
- B. Cleaning the incision only when serous exudate forms
- C. Rubbing the incision gently with a sterile cotton-tipped swab
- D. Replacing the Logan bar carefully after cleaning the incision
Correct Answer: A
Rationale: The incision should be rinsed with sterile water after every feeding. Rubbing alters the integrity of the suture line. Rather, the incision should be patted or dabbed. The purpose of the Logan bar is to maintain the integrity of the suture line. Removing the Logan bar on the first postoperative day would increase tension on the surgical incision.
The nurse monitors the client taking amitriptyline for which common side effect?
- A. Diarrhea
- B. Drowsiness
- C. Hypertension
- D. Increased salivation
Correct Answer: B
Rationale: Common side effects of amitriptyline (a tricyclic antidepressant) include the central nervous system effects of drowsiness, fatigue, lethargy, and sedation. Other common side effects include dry mouth or eyes, blurred vision, hypotension, and constipation. The nurse monitors the client for these side effects.
The nurse, caring for a client who has been placed in Buck's extension traction while awaiting surgical repair of a fractured femur, should perform a complete neurovascular assessment of the affected extremity that include which interventions? Select all that apply.
- A. Vital signs
- B. Bilateral lung sounds
- C. Pulse in the affected extremity
- D. Level of pain in the affected leg
- E. Skin color of the affected extremity
- F. Capillary refill of the affected toes
Correct Answer: C,D,E,F
Rationale: A complete neurovascular assessment of an extremity includes color, sensation, movement, capillary refill, and pulse of the affected extremity. Options 1 and 2 are not related to neurovascular assessment.
The nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress syndrome (RDS). Which assessment finding indicates that the neonate's respiratory condition is improving?
- A. Edema of the hands and feet
- B. Urine output of 3 mL/kg/hour
- C. Presence of a systolic murmur
- D. Respiratory rate between 60 and 70 breaths per minute
Correct Answer: B
Rationale: RDS is a serious lung disorder caused by immaturity and the inability to produce surfactant, resulting in hypoxia and acidosis. Lung fluid, which occurs in RDS, moves from the lungs into the bloodstream as the condition improves and the alveoli open. This extra fluid circulates to the kidneys, which results in increased voiding. Therefore, normal urination is an early sign that the neonate's respiratory condition is improving (normal urinary output is 2 to 5 mL/kg/hour). Edema of the hands and feet occurs within the first 24 hours after the development of RDS as a result of low protein concentrations, a decrease in colloidal osmotic pressure, and transudation of fluid from the vascular system to the tissues. Systolic murmurs usually indicate the presence of a patent ductus arteriosus, which is a common complication of RDS. Respiratory rates above 60 are indicative of tachypnea, which is a sign of respiratory distress.
When tranylcypromine is prescribed for a client, which food items should the nurse instruct the client to avoid? Select all that apply.
- A. Figs
- B. Apples
- C. Bananas
- D. Broccoli
- E. Sauerkraut
- F. Baked chicken
Correct Answer: A,C,E
Rationale: Tranylcypromine is a monoamine oxidase inhibitor (MAOI) used to treat depression. Foods that contain tyramine need to be avoided because of the risk of hypertensive crisis associated with use of this medication. Foods to avoid include figs; bananas; sauerkraut; avocados; soybeans; meats or fish that are fermented, smoked, or otherwise aged; some cheeses; yeast extract; and some beers and wine.