Nokea
The nurse is talking with the parent of a 5-year-old client about managing recurrent nosebleeds at home. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Apply direct pressure by pinching your child's nostrils together for 5-15 minutes.
- B. Take your child to the emergency department as soon as possible.
- C. Tell your child to lie down and turn your child on the left side.
- D. Provide reassurance to keep your child calm and quiet.
- E. Place a cold cloth over the bridge of your child's nose.
Correct Answer: A,D,E
Rationale: Pressure , reassurance , and cold cloth control bleeding and anxiety. ED visits are unnecessary for recurrent nosebleeds, and lying down risks aspiration.
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A client with multiple sclerosis is voicing concerns to the nurse about incoordination when walking. Which of the following instructions by the nurse would be most appropriate at this time?
- A. Avoid excess stretching of your lower extremities.
- B. Build strength by increasing the duration of daily exercise.
- C. Let me speak with your health care provider about getting a wheelchair.
- D. You should keep your feet apart and use a cane when walking.
Correct Answer: D
Rationale: A wide stance and cane improve balance. Stretching is beneficial, prolonged exercise may worsen fatigue, and a wheelchair is premature.
The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?
- A. cyanosis resolves in the knee-chest position
- B. weight gain of 0.6 lb (0.27 kg) since birth
- C. hematocrit level of 67% (0.67)
- D. murmur noted on auscultation
Correct Answer: C
Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.
The nurse in the outpatient clinic is caring for a client whose obstetric history is documented as G3 T1 P2 A1 L2. The nurse should recognize that the client
- A. has 3 living children
- B. is currently not pregnant
- C. had 1 live birth after 37 weeks gestation
- D. had 3 births between 20 weeks and 36 weeks gestation
Correct Answer: C
Rationale: G3 indicates 3 pregnancies; T1 means 1 term birth (37 weeks); P2 means 2 preterm births (20-36 weeks); A1 means 1 abortion; L2 means 2 living children. Thus, C is correct as it matches T1.
The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?
- A. I can come back at the end of my shift when I am able to stay longer.
- B. I will ask a friend or family member to stay with you if you would like.
- C. I can stay and sit with you for a short time if you would like.
- D. I will contact the chaplain to sit with you and your spouse
Correct Answer: C
Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.
The nurse is inserting an indwelling urinary catheter for a female client. Which of the following actions should the nurse take? Select all that apply.
- A. Use the nondominant hand to gently spread the labia folds
- B. Apply sterile gloves and place the drape under the client's buttocks.
- C. Insert and advance the catheter 2 in (5 cm) and then inflate the balloon
- D. Place the client on the back with the knees flexed and hips rotated externally.
- E. Cleanse the labia majora and labia minora before cleansing the urinary meatus
Correct Answer: A,B,D
Rationale: Spreading labia aids visualization. Sterile gloves and drape maintain sterility. Proper positioning facilitates insertion. Advancing only 2 inches is insufficient (should be 5-7 cm) before balloon inflation. Cleansing should start with the meatus , not labia.