Nokea
A 70-year-old male client with type 2 diabetes mellitus (DM) is hospitalized with an infected ulcer on his great right toe. Which instruction should the nurse emphasize during discharge teaching?
- A. Check the insides and linings of all enclosed shoes before putting the shoes on
- B. Wash the feet with soap and water, then apply a topical antibiotic ointment.
- C. Trim toenails weekly to prevent injury.
- D. Avoid wearing sandals or open-toed shoes.
Correct Answer: A
Rationale: Preventing trauma to the feet is critical for clients with diabetes to avoid complications like infections and ulcers.
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A nurse assesses an older adult client who has multiple chronic diseases. The client’s heart rate is 48 beats/min. Which action should the nurse take first?
- A. Document the finding in the chart.
- B. Initiate external pacing.
- C. Assess the client’s medications.
- D. Administer 1 mg of atropine.
Correct Answer: C
Rationale: A heart rate of 48 beats/min (bradycardia) in an older adult with multiple chronic diseases may be due to medication side effects. Assessing the client’s medications is the first step to determine if any drugs are contributing to the bradycardia.
An adolescent who sustained a tibia fracture in a motor vehicle accident has a cast. What should the nurse do to help relieve the itching?
- A. Apply cool air under the cast with a blow-dryer
- B. Use sterile applicators to scratch the itch
- C. Apply cool water under the cast
- D. Apply hydrocortisone cream under the cast using sterile applicator
Correct Answer: A
Rationale: Cool air helps relieve itching without damaging the cast or introducing moisture, which can lead to skin breakdown.
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client plan of care?
- A. Continuous cardiac monitoring
- B. Perform passive range of motion
- C. Evaluate level of consciousness
- D. Assess lung sounds q4 hours.
Correct Answer: A
Rationale: Electrical injuries can cause cardiac arrhythmias, so continuous cardiac monitoring is critical to detect and manage any life-threatening complications.
Which of the following is correct in breast milk jaundice?
- A. Peaks at first week of life
- B. Recurs with resumption of breast milk after trial stoppage
- C. Kernicterus can occur
- D. Seen in up to 10% of infants
Correct Answer: B
Rationale: Breast milk jaundice recurs when breastfeeding is resumed after a temporary stoppage.
Regarding cystic fibrosis:
- A. It is inherited as autosomal recessive
- B. There is increased risk of bronchial carcinoma in late adulthood
- C. Biliary cirrhosis is a recognised feature
- D. In neonates, intestinal obstruction may be the first presentation
Correct Answer: A
Rationale: Cystic fibrosis is an autosomal recessive disorder caused by mutations in the CFTR gene.