Nokea
A client who is 2 days post-operative from an appendectomy requests medication for pain. The client's vital signs are as follows: pulse 96, respirations 30, BP 130/92. The nurse should:
- A. Ask whether the client is anxious.
- B. Give the pain medication.
- C. Check the dressing for bleeding.
- D. Recheck the client's vital signs.
Correct Answer: B
Rationale: Pain medication is appropriate for a post-op client with pain and stable vitals. Anxiety may contribute, but pain should be addressed first. Bleeding checks or rechecking vitals are unnecessary without specific indicators.
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A child and his family were exposed to Mycobacterium tuberculosis about 2 months ago, to confirm the presence or absence of an infection, it is most important for all family members to have a
- A. Chest x-ray
- B. Blood culture
- C. Sputum culture
- D. PPD intradermal test
Correct Answer: D
Rationale: PPD intradermal test. The administration of the PPD intradermal test determines the presence of the infection with the Mycobacterium tuberculosis organism. It is effective at 3 to 6 weeks after the initial infection.
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.'
- B. Oh, that is expected, so I would just ignore the behavior.'
- C. Perhaps you could gradually leave for short periods.'
- D. You should leave quickly to minimize the child's distress.'
Correct Answer: C
Rationale: Gradually increasing the time of separation can help the child adjust to the mother's absence, reducing anxiety and screaming over time.
A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?
- A. Apply lubricating eye drops when wearing contacts
- B. Do not break, crush, or chew capsules
- C. Use sunscreen routinely during therapy
- D. Use two forms of contraception consistently
Correct Answer: D
Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (D) is critical to prevent pregnancy. Sunscreen (C) is important for photosensitivity, but contraception is the priority.
A client who had a total knee replacement is to be discharged today. Which statement that the client makes indicates a need for further instruction?
- A. When I am walking, I will wear that ugly immobilizer.'
- B. I will sit with my leg elevated.'
- C. I think I understand how to use the continuous passive motion machine.'
- D. I won't put any weight at all on my affected leg.'
Correct Answer: D
Rationale: Total knee replacement typically allows partial weight-bearing with assistance post-surgery; complete non-weight-bearing suggests misunderstanding of mobility instructions.
The nurse's neighbor calls the nurse and asks for assistance with her child who developed a nosebleed after being hit in the nose by a ball. What should the nurse recommend to the neighbor?
- A. Pinch the child's nose and bend the head forward.
- B. Pinch the child's nose and bend the head backward.
- C. Put ice on the nose and call 911 immediately.
- D. Stuff cotton up both nostrils and bend the head backward.
Correct Answer: A
Rationale: Pinching the nose and leaning forward compresses the bleeding site and prevents blood swallowing, effectively managing a nosebleed caused by trauma.