Nokea
A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to reinforce to the parents in order to prevent recurrence?
- A. Exclusive breastfeeding
- B. Not sending the child to day care
- C. Preventing water from entering the ear
- D. Smoking cessation by the parents
Correct Answer: D
Rationale: Parental smoking increases the risk of recurrent otitis media due to secondhand smoke exposure.
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An adult is hospitalized following a myocardial infarction. While the client is receiving heparin, the nurse should have which of the following medications available?
- A. Aspirin
- B. Calcium gluconate
- C. Vitamin K
- D. Protamine sulfate
Correct Answer: D
Rationale: Protamine sulfate is the antidote for heparin overdose, reversing its anticoagulant effects in case of bleeding.
An adult woman has been diagnosed with varicose veins. Which aspect of her history is most likely related to her diagnosis?
- A. She has had five term pregnancies.
- B. She runs several marathons a year.
- C. She is 5 feet, 6 inches tall and weighs 120 pounds.
- D. She works entering data into a computer.
Correct Answer: A
Rationale: Multiple pregnancies increase intra-abdominal pressure and venous stasis, contributing to varicose veins. Running, normal weight, and sedentary work are less directly related.
An adult who is scheduled for surgery tomorrow asks the nurse to arrange for his Healing Touch practitioner to give him healing touch treatments after surgery. The client's daughter who hears the request asks the nurse to explain how Healing Touch can help her father. What information should the nurse include in the response?
- A. Healing Touch makes use of the power of suggestion and can help the person feel more comfortable.
- B. No one really knows how it works, but if a person really wants it, it certainly will not hurt.
- C. The Healing Touch practitioner works within the energy field around the person to facilitate healing and pain relief.
- D. Healing Touch is similar to acupuncture except that pressure is used instead of needles.
Correct Answer: C
Rationale: Healing Touch involves manipulating the energy field to promote healing and pain relief, a recognized complementary therapy.
As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.
- A. I should rinse my mouth with water before collecting the sputum.
- B. I will be careful not to touch the inside of the specimen cup or lid.
- C. I will inhale deeply a few times and then cough forcefully.
- D. It is best to collect the sputum mid-day when my secretions are loose.
- E. It is helpful if I am sitting upright when I collect the sputum.
Correct Answer: A,B,C,E
Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.