Nokea
A LPN/LVN contacts the nurse to say that s/he has shingles on her/his back. Which of the following statements by the nurse is BEST?
- A. You can't take care of clients for fourteen days.
- B. Come to work as scheduled.
- C. You can't care for clients until the lesions are crusted.
- D. Please contact your physician.
Correct Answer: B
Rationale: Localized shingles allows work if lesions are covered, as with back lesions. Options A, C, and D are overly restrictive or unnecessary.
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A Hispanic client refuses emergency room treatment until a curandero is called. The nurse understands that this person brings what to situations of illness?
- A. Holistic healing
- B. Spiritual advising
- C. Herbal preparations
- D. Witchcraft potions
Correct Answer: A
Rationale: Holistic healing. This traditional folk practitioner uses holistic methods for illnesses, often working with traditional health care providers.
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
The nurse is caring for a client who is receiving a continuous IV infusion of nitroglycerin for chest pain. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 100/60 mmHg
- B. Heart rate of 80 bpm
- C. Respiratory rate of 18 breaths/min
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: Hypotension (100/60 mmHg) is a serious nitroglycerin side effect, risking inadequate perfusion. Options B, C, and D are normal findings.
Which item should be kept at the bedside of a client who has just returned from having a thyroidectomy?
- A. A padded tongue
- B. An endotracheal tube
- C. An airway
- D. A tracheostomy set
Correct Answer: D
Rationale: A tracheostomy set is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy. Options A, B, and C are less critical in this context.
Which of the following statements best describes the gross motor development of a 2-year old?
- A. She skips without falling.
- B. She walks up and down stairs.
- C. She rides a tricycle.
- D. She is able to broad jump.
Correct Answer: B
Rationale: A 2-year-old can typically walk up and down stairs with support, a key gross motor milestone. Skipping , riding a tricycle , and broad jumping are skills developed later, around 3-5 years.