Nokea
A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.
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The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.
- A. Administer a prescribed analgesic 30 minutes before irrigating the wound
- B. Cleanse the wound from the most contaminated to the least contaminated area
- C. Obtain a 10-mL syringe and a 27-gauge needle
- D. Review the client's vaccination record
- E. Use continuous pressure to flush the wound and repeat until the drainage is clear
Correct Answer: A,D,E
Rationale: Analgesics (A), checking vaccinations (D) for tetanus risk, and continuous flushing (E) are appropriate. Cleaning from contaminated to clean (B) is incorrect, and a 27-gauge needle (C) is too small for irrigation.
The nurse prepares to insert an indwelling urinary catheter in a client who is disoriented to time, place, and person and cannot follow directions or commands. Which intervention is most important when inserting the urinary catheter?
- A. Ensure the client understands the procedure prior to implementation
- B. Maintain a sterile field and keep the urinary catheter sterile
- C. Place the catheter supply kit between the client's legs in the center of the bed
- D. Throw swabs used to clean the perineum directly into the biohazard bin
Correct Answer: B
Rationale: Maintaining a sterile field (B) is critical to prevent infection, especially in a disoriented client. Explaining the procedure (A) is ideal but not feasible, kit placement (C) is secondary, and swab disposal (D) follows insertion.
The nurse is caring for a 12-month-old client who is HIV-positive and severely immunosuppressed. Which of the following scheduled immunizations should the nurse anticipate administering to the client? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis A
- C. Measles, mumps, rubella
- D. Pneumococcal conjugate vaccine
- E. Varicella
Correct Answer: A,D
Rationale: Hib (A) and PCV (D) are inactivated vaccines, safe for immunosuppressed children. MMR (C) and varicella (E) are live vaccines, contraindicated. Hepatitis A (B) is not routine at 12 months.
The nurse is caring for a client who has bleeding esophageal varices. What should the nurse expect might develop in this client? Select all that apply.
- A. Confusion
- B. Tarry stools
- C. Lower abdominal pain and pressure
- D. High blood pressure
- E. Tremors
- F. Hallucinations
Correct Answer: A,B
Rationale: Bleeding varices cause blood loss, leading to tarry stools (melena) from digested blood and confusion from hepatic encephalopathy due to liver dysfunction. Abdominal pain, hypertension, tremors, or hallucinations are less directly related.
The nurse is teaching a group of parents about gross motor development of a 2-year old. According to the Denver Developmental Screening Test, which behavior is an example of the normal gross motor skill of a 2-year old?
- A. She can pull a toy behind her.
- B. She can copy a horizontal line.
- C. She can build a tower of eight blocks.
- D. She can broad jump.
Correct Answer: A
Rationale: Pulling a toy is a gross motor skill for a 2-year-old per the Denver Test. Copying a line and building a tower of eight blocks are fine motor skills. Broad jumping develops later.