Nokea
A 4-year-old girl has been transferred to a step-down recovery room after a tonsillectomy yesterday. The nurse should place the child in what position while she sleeps?
- A. semi-Fowler's position
- B. supine position
- C. prone position
- D. side-lying position
Correct Answer: D
Rationale: Side-lying position post-tonsillectomy promotes drainage of secretions, reducing airway obstruction risk.
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The nurse is teaching a client with a new colostomy about dietary management. Which of the following foods should the nurse recommend the client avoid to reduce odor and gas?
- A. Broccoli.
- B. Baked chicken.
- C. Rice.
- D. Yogurt.
Correct Answer: A
Rationale: broccoli is a gas-forming food that can increase odor and gas in a colostomy
The initial assessment of a newborn reveals a chest circumference of 34 cm and an abdominal circumference of 31 cm. The chest is asymmetrical and breath sounds are diminished on the left side. The nurse should give priority to:
- A. Providing supplemental oxygen by a ventilated mask
- B. Performing auscultation of the abdomen for the presence of active bowel sounds
- C. Inserting a nasogastric tube to check for esophageal patency
- D. Positioning on the left side with head and chest elevated
Correct Answer: A
Rationale: Diminished breath sounds and chest asymmetry suggest a respiratory issue, such as pneumothorax, requiring immediate supplemental oxygen.
A client is admitted with a blood alcohol level of 180 mg/dL. The nurse recognizes that the alcohol in the client's system should be fully metabolized within:
- A. 3 hours
- B. 5 hours
- C. 7 hours
- D. 9 hours
Correct Answer: D
Rationale: A blood alcohol level of 180 mg/dL (0.18%) typically takes about 9 hours to metabolize, assuming a metabolism rate of 0.02% per hour.
The nurse is caring for a client with cancer who is exhibiting signs and symptoms that death is near. The client's daughter says that she does not want her mother to receive morphine because it will hasten her death. What response by the nurse is most appropriate?
- A. We always give morphine to clients at the end-of-life stage.
- B. We can give oxygen instead of morphine to help with breathing and distress.
- C. Morphine will reduce anxiety and reduce the sensation of air hunger in your mother.
- D. We will wait until the very end to give the morphine and use nonpharmacologic measures instead.
Correct Answer: C
Rationale: Morphine alleviates air hunger and anxiety in end-of-life care, improving comfort without necessarily hastening death, addressing the daughter’s concerns therapeutically.
The nurse is caring for an 11-year-old patient being treated for a fractured right femur with balanced suspension traction with a Thomas splint and Pearson attachment. The nurse notes that the patient’s left leg is externally rotated. The nurse should
- A. place a trochanter roll on the outer aspect of the thigh.
- B. perform resistive range of motion of the left leg.
- C. adduct and internally rotate the left leg.
- D. instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: holds hip in neutral position and leg in normal alignment, entire weight of leg cannot be held by props placed below knee