Nokea
A 2-year old is hospitalized with gastroenteritis and dehydration. Which of the following methods is best for evaluating changes in skin turgor?
- A. Pinching the abdominal tissue while the client is supine
- B. Pinching the tissue of the forearm while the client is sitting
- C. Pressing the skin of the lower extremities while the client is supine
- D. Pinching the skin of the lower extremities while the client is sitting
Correct Answer: A
Rationale: Pinching abdominal tissue while supine is the best method to assess skin turgor in a dehydrated child, as it reflects hydration status accurately.
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The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.
- A. Do not leave a tourniquet on more than 1 minute while looking for a vein
- B. Draw the specimen while the skin is still wet with the alcohol prep
- C. If pulsating red blood is noted, withdraw the needle and apply pressure for 5 minutes
- D. Use a highly visible vein on the ventral side of the client's wrist
- E. Vigorously shake the specimen tube to mix obtained blood with anticoagulant solution
Correct Answer: A,C
Rationale: A tourniquet left on too long (A) can cause hemoconcentration, so it should be removed after 1 minute. Pulsating blood (C) indicates arterial puncture, requiring immediate needle withdrawal and pressure to prevent hematoma. Wet alcohol (B) can cause hemolysis, and the ventral wrist (D) is a risky site due to nerves and arteries. Vigorous shaking (E) damages blood cells, so gentle inversion is preferred.
The nurse is reinforcing teaching to the caregiver of a child diagnosed with ringworm on the abdomen. Which statement by the caregiver indicates a need for further teaching?
- A. Handwashing is very important as ringworm can be spread among humans and pets.
- B. I must apply antifungal cream to all affected areas to eradicate ringworm from the body.
- C. My child has been infected by a worm and must be treated to rid it from the body.
- D. My child may be uncomfortable due to itching, but this is not a dangerous condition.
Correct Answer: C
Rationale: Ringworm is a fungal infection, not a parasitic worm (C), indicating a misunderstanding requiring further teaching. Handwashing (A), antifungal cream (B), and recognizing itching as non-dangerous (D) are correct, reflecting proper understanding.
The nurse is caring for a client with COPD who becomes dyspneic. The nurse should
- A. instruct the client to breathe into a paper bag
- B. place the client in a high Fowler's position
- C. assist the client with pursed lip breathing
- D. administer oxygen at 6L/minute via nasal cannula
Correct Answer: C
Rationale: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.
In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
- A. Uterine atony
- B. Genital lacerations
- C. Retained placenta
- D. Clotting disorder
Correct Answer: B
Rationale: Genital lacerations. Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.
The nurse is caring for a 7 year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?
- A. Report a persistent cough to the health care provider
- B. The child can return to school in 4 days
- C. Administer chewable aspirin for pain
- D. The child may gargle with saline as necessary for discomfort
Correct Answer: A
Rationale: Report a persistent cough to the health care provider. Persistent coughing may indicate bleeding, which requires immediate attention.