Nokea
A 15-year-old client visits the clinic to get medical clearance to play a sport.
- A. "I will avoid showering at the gym."'
- B. "I can apply an antifungal cream daily."'
- C. "I should wear dark-colored socks."'
- D. "I should wear well-ventilated shoes."'
Correct Answer: D
Rationale: The correct answer is D: "I should wear well-ventilated shoes." This is because well-ventilated shoes help prevent fungal infections by keeping the feet dry and reducing moisture buildup, which is crucial for active individuals like athletes. Choice A is incorrect as avoiding showering at the gym is not a practical solution for preventing fungal infections. Choice B, applying antifungal cream daily, is reactive rather than preventive. Choice C, wearing dark-colored socks, does not directly address the issue of moisture and ventilation.
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A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?
- A. I can administer oxytocin 4 hours after the insertion of the medication
- B. You will need a full bladder prior to the insertion of the medication
- C. Remain in a side-lying position for 15 minutes after the medication is inserted
- D. An antacid will be given 20 minutes prior to the insertion of the medication
Correct Answer: C
Rationale: The correct answer is C: Remain in a side-lying position for 15 minutes after the medication is inserted. This instruction is important because misoprostol can cause uterine contractions leading to potential discomfort or cramping. By remaining in a side-lying position, the client can help the medication remain in the desired location near the cervix, enhancing its effectiveness. This position also helps reduce the risk of the medication leaking out prematurely and ensures optimal absorption.
Choice A is incorrect because oxytocin is not typically administered shortly after misoprostol due to the potential for excessive uterine stimulation. Choice B is incorrect as a full bladder is not necessary for the insertion of misoprostol. Choice D is incorrect as an antacid is not typically required prior to the insertion of misoprostol.
A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.
A women in her first trimester contracts rubella. How is the fetus likely to be affected?
- A. Reproductive and urinary defects
- B. Heart defects and cataracts
- C. Spinal cord and skeletal defects
- D. Polydactyly and club feet
Correct Answer: B
Rationale: The correct answer is B: Heart defects and cataracts. Rubella infection during the first trimester can lead to congenital rubella syndrome, causing heart defects and cataracts in the fetus. Rubella affects organ development during this critical period. Choice A is incorrect as rubella does not typically cause reproductive and urinary defects. Choice C is incorrect because rubella does not usually result in spinal cord and skeletal defects. Choice D is incorrect as polydactyly and club feet are not typical manifestations of rubella infection during pregnancy.
A client is admitted to the hospital with severe pregnancy-induced hypertension (PIH). The physician orders magnesium sulfate. Which nursing intervention is important when administering this drug?
- A. Assess blood pressure and respiratory rate every fifteen minutes
- B. Monitor blood glucose levels every eight hours
- C. Evaluate for orthostatic hypotension when getting the client up to walk
- D. Observe for premature labor every shift
Correct Answer: A
Rationale: The correct answer is A because magnesium sulfate is a central nervous system depressant used to prevent seizures in PIH. It can cause respiratory depression and hypotension. Assessing blood pressure and respiratory rate every fifteen minutes is crucial to monitor for signs of magnesium toxicity and ensure the client's safety. Monitoring blood glucose levels (B) is not directly related to magnesium sulfate administration. Evaluating for orthostatic hypotension (C) and observing for premature labor (D) are not specific to the administration of magnesium sulfate in treating PIH.
A nurse is caring for an infant with a history of vomiting due to gastroenteritis. Which of the following nursing interventions is considered the priority?
- A. Place the infant in a side or semi-reclined position.
- B. Administer oral rehydration and electrolyte therapy.
- C. Administer antiemetic medications as prescribed.
- D. Maintain a high-carbohydrate intake to prevent ketosis.
Correct Answer: A
Rationale: Positioning the infant prevents aspiration, which is the highest priority.