Nokea
A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if he can swim in the family pool. The best response from the nurse is
- A. Your child should not swim at all while the tubes are in place.'
- B. Your child may swim in your own pool but not in a lake or ocean.'
- C. Your child may swim if he wears ear plugs.'
- D. Your child may swim anywhere.'
Correct Answer: C
Rationale: Water should not enter the ears. Children should use ear plugs when bathing or swimming and should not put their heads under the water.
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A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
- A. Cessation of contractions and maternal tachycardia
- B. Fetal tachycardia with moderate variability
- C. Increased anxiety and discomfort with contractions
- D. Painful, strong contractions every 3-4 minutes
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (B) is concerning but less specific, anxiety (C) is expected, and regular contractions (D) are normal.
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 observes a client using a walker. Which observation indicates that the client needs more instruction?
- A. The client uses the walker to pull herself out of a chair.
- B. The client moves the walker forward and then takes a step.
- C. The client complains that the walker is not waist high.
- D. The client sometimes does not use the walker.
Correct Answer: A
Rationale: Using the walker to pull up risks tipping, indicating improper use and a need for further instruction on safe walker technique.
The nurse is planning care for all of the following clients. Which client should be cared for first?
- A. A 60-year-old who is three days postop and needs a dressing change and ambulation
- B. A 75-year-old who had a suprapubic prostatectomy yesterday and says, 'Take that tube out of me, I have to pee.'
- C. A 90-year-old who had a total hip replacement two days ago and is to get out of bed today
- D. A 50-year-old who had an abdominal cholecystectomy yesterday and is asking for pain medication
Correct Answer: B
Rationale: The 75-year-old post-prostatectomy client's request to remove the catheter and urgency to urinate suggest potential catheter obstruction or bladder irritation, which could lead to complications like infection or bladder damage. This requires immediate assessment and intervention, taking priority over routine dressing changes, scheduled mobility, or pain management.
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with over dosage?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct Answer: B
Rationale: Lidocaine Hydrochloride can cause fatigue and confusion if an over dosage occurs.