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A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching?
- A. I will launder recently worn clothing, sheets, and towels in hot water.'
- B. I will make sure all eating utensils are placed in the dishwasher.'
- C. I will spray the house with insecticide to control this problem.'
- D. I will throw away stuffed animals and toys that cannot be washed.'
Correct Answer: A
Rationale: Laundering clothing, sheets, and towels in hot water effectively kills lice and nits, indicating understanding. Dishwashing utensils is irrelevant, spraying insecticide is unnecessary, and discarding toys is excessive if they can be sealed or washed.
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The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention?
- A. Administer oxygen via nasal cannula for client comfort and safety
- B. Clean area with povidone iodine in a circular motion moving outward
- C. Hold the child with the head and knees tucked in and the back rounded out
- D. Monitor and record vital signs every 15 minutes throughout the procedure
Correct Answer: C
Rationale: During a lumbar puncture for an infant, holding the child in a flexed position with head and knees tucked and back rounded ensures proper spinal alignment for safe needle insertion. Oxygen is not routinely needed, cleaning is typically done by the provider, and vital sign monitoring is important but not the primary intervention.
The nurse is to administer an iron injection to an adult. How should this be administered?
- A. Subcutaneous in the arm
- B. Intradermal in the forearm
- C. Intramuscular in the deltoid
- D. Z track intramuscular in the gluteal
Correct Answer: D
Rationale: Iron injections are given via Z-track intramuscular in the gluteal muscle to prevent leakage and skin staining, ensuring deep muscle administration.
A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
- A. I am very tired, and it's hard for me to keep my eyes open.'
- B. I don't feel good, and I want to be seen.'
- C. I have not taken my blood pressure medicine in over a week.'
- D. I have the worst headache I've ever had in my life.'
Correct Answer: D
Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B, C) are less specific.
An 80-year-old woman is having difficulty sleeping. Which nursing action is most appropriate initially?
- A. Ask the physician for an order for a sleeping medication.
- B. Encourage the client to do mild exercises a half hour before going to bed.
- C. Suggest to the client that she not nap during the day.
- D. Recommend the client drink coffee in the evening.
Correct Answer: C
Rationale: Avoiding daytime naps improves nighttime sleep hygiene, a non-pharmacologic initial approach suitable for an elderly client.
The practical nurse is assisting the registered nurse during admission of a client with heart failure-related fluid overload. Which action should be completed first?
- A. Administer oxygen
- B. Assess the client's breath sounds
- C. Initiate cardiac monitoring
- D. Insert a peripheral IV catheter
Correct Answer: B
Rationale: Assessing breath sounds is the first step to evaluate the extent of fluid overload and guide interventions in heart failure. Oxygen , monitoring , and IV insertion follow based on findings.