Nokea
A child comes to the school nurse with a honey-colored crusted lesion below her right nostril. Which of the following actions should the nurse take FIRST?
- A. Remove the scab.
- B. Apply a wet cloth to the lesion.
- C. Notify the child's parents.
- D. Contact the health department.
Correct Answer: C
Rationale: describes impetigo, highly infectious superficial bacterial infection; notify parents so they can contact the physician
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A patient is admitted with abdominal pain and nausea. The physician orders stool for guaiac times three days.
The nurse asks the health care technician to obtain the stool specimen. Which of the following statements, if made by the technician, would require an intervention by the nurse?
- A. I'll remind the patient to use the bedpan instead of the bathroom toilet.
- B. I'll use a tongue blade to collect a small amount of stool in a clean container.
- C. I'll get a couple of specimens this afternoon because the patient is having loose stools.
- D. I'll ask the patient if he has ingested any red meat recently.
Correct Answer: C
Rationale: Strategy: Each answer choice is an implementation. Determine the outcome of each answer choice. Is it desired? (1) easier to get specimen (2) doesn't need to be sterile container (3) correct-ordered to be collected over 3-day period (4) may cause false-positive reading
While performing care for a 72-year-old woman, the nurse notices that the patient has a dry, parched mouth and tongue. The nurse should
- A. brush the patient's teeth with a hard-bristled toothbrush before meals and at bedtime.
- B. use glycerin swabs to perform mouth care every 4 hours.
- C. rinse the patient's mouth with room-temperature tap water before and after meals.
- D. use a water pick, then rinse with commercial mouthwash every 8 hours to freshen the mouth.
Correct Answer: C
Rationale: will hydrate the mucous membranes and keep mouth clean
The nurse is caring for clients in the hospital. Which of the following nursing activities BEST promotes rest for an elderly hospitalized client?
- A. Place a clock at the bedside.
- B. Restrict visitors so that the client is alone during the evening.
- C. Tell the client how to call for help if needed.
- D. Postpone explanation of further tests that the client will need.
Correct Answer: C
Rationale: elderly client who feels isolated and unable to obtain help if needed cannot rest properly
The nurse is caring for a client with a history of depression who is receiving fluoxetine (Prozac) 20 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about ending my life.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of ending life indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on fluoxetine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia?
- A. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established.
- B. To decrease the risk of aspiration, the client must be NPO at least 12 hours prior to the initiation of the anesthesia.
- C. Assess the client for any allergies to Betadine or iodine preparations.
- D. Determine the specific gravity of the urine and prepare the client for insertion of a central line.
Correct Answer: A
Rationale: Spinal anesthesia causes vasodilation, risking hypotension; hydration is critical. Options B, C, and D are excessive or unrelated.