Nokea
A mother calls the clinic, concerned that her 5 week-old infant is 'sleeping more than her brother did.' What is the best initial response?
- A. Do you remember his sleep patterns?'
- B. How old is your other child?'
- C. Why do you think this a concern?'
- D. Does the baby sleep after feeding?'
Correct Answer: C
Rationale: Open ended questions encourage further discussion and conversation, thereby eliciting further information.
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A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
- A. Orange juice, baked chicken, and a cucumber and tomato salad
- B. Milk, roast beef, and spinach salad
- C. Iced tea, fish sandwich, and mixed vegetables
- D. Cola, fried shrimp, and coleslaw
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
A wet-to-dry dressing is ordered for a client who has a decubitus ulcer. Which technique is appropriate?
- A. Irrigate the wound and then apply a dry dressing and cover with a wet compress.
- B. Apply a wet dressing for two hours followed by a dry dressing for two hours.
- C. Apply a wet dressing, and cover with a dry dressing.
- D. Apply a wet dressing above the wound and a dry dressing below the wound.
Correct Answer: C
Rationale: Wet-to-dry dressings involve a moist gauze applied to the wound, covered with dry gauze, to debride tissue as it dries. Other techniques are incorrect.
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.
- A. What should the nurse do if the patient’s left leg is externally rotated?
- B. Place a trochanter roll on the outer aspect of the thigh.
- C. Perform resistive range of motion of the left leg.
- D. Adduct and internally rotate the left leg.
- E. Instruct the patient to maintain the left leg in a neutral position.
Correct Answer: A
Rationale: A trochanter roll placed on the outer aspect of the thigh prevents external rotation by holding the hip in a neutral position and maintaining normal leg alignment. Resistive exercises, manual repositioning, or instructing the patient to maintain position are less effective, as they do not provide sustained support to prevent rotation.
An older adult is admitted with severe pneumonia. Which of the following measures should the nurse include in the plan of care immediately after admission? Select all that apply.
- A. Encourage the client to drink 2 L of fluid daily.
- B. Administer antipyretics as ordered.
- C. Administer antibiotics as ordered.
- D. Administer mucolytics as ordered.
- E. Ambulate three times a day.
- F. Eat three large meals a day.
Correct Answer: A,B,C,D
Rationale: Fluids hydrate and thin secretions, antipyretics control fever, antibiotics treat infection, and mucolytics aid mucus clearance in pneumonia. Ambulation and large meals may be inappropriate initially due to fatigue.
A 10-year-old for a cardiac catheterization.
Which of the following plans would be MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
- A. Show a videotape specifically prepared for children about cardiac catheterization.
- B. Provide the child with a pamphlet about the procedure and encourage him to read it.
- C. Draw a picture of a heart and explain where the tube will go and what the doctor will see.
- D. Present a puppet show explaining the anatomy and physiology of the heart.
Correct Answer: C
Rationale: Strategy: Think about the developmental stage of a 10-year-old. (1) video will provide correct information but is not best preparation for a school-age child (2) pamphlet will contain correct information but is not best preparation for a school-age child (3) correct-this plan will best prepare the child for the procedure (4) would be more appropriate for a younger child