Nokea
A nurse is caring for a client who has a new diagnosis of Lyme disease. Which of the following findings should the nurse expect?
- A. Bull's-eye rash
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: A bull's-eye rash (erythema migrans) is a classic early sign of Lyme disease at the site of the tick bite.
You may also like to solve these questions
A nurse is assisting with the care of a client who is receiving a continuous tube feeding. Which of the following actions should the nurse take?
- A. Check gastric residual volume every 8 hours.
- B. Flush the tube with cold water every 4 hours.
- C. Position the client flat during feeding.
- D. Change the feeding bag every 72 hours.
Correct Answer: C
Rationale: Positioning the client with the head of the bed elevated during feeding reduces the risk of aspiration, a critical safety measure.
A nurse is reinforcing teaching with a client who has a new prescription for a clonidine patch. Which of the following instructions should the nurse include?
- A. Apply the patch to the same site each week.
- B. Remove the patch after 12 hours.
- C. Apply the patch to the upper arm.
- D. Leave the patch on for 48 hours.
Correct Answer: C
Rationale: Applying the clonidine patch to the upper arm (or other recommended sites) ensures effective delivery of the medication.
A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?
- A. Oranges
- B. Potatoes
- C. Grapes
- D. Corn
Correct Answer: C
Rationale: Grapes are correct. Whole grapes are a known choking hazard for toddlers due to their size and shape, which can easily obstruct the airway. They should be cut into smaller pieces to reduce the risk.
A nurse overhears two assistive personnel discussing a client's medical history in the hallway. Which of the following actions should the nurse take first?
- A. Report the incident to the charge nurse.
- B. Tell the staff members to stop their discussion.
- C. Participate in an in-service about client confidentiality.
- D. Speak to the staff members in private about client confidentiality.
Correct Answer: B
Rationale: Telling the staff members to stop their discussion is correct. The nurse should immediately address the situation by asking the APs to stop discussing the client's medical history in the hallway to protect client confidentiality. This is the most immediate and effective action in ensuring the client's privacy is respected.
A nurse is reinforcing teaching with a client who is scheduled for a cardiac MRI. Which of the following instructions should the nurse include?
- A. Remove all metal objects before the procedure.
- B. Fast for 12 hours before the procedure.
- C. Expect to receive general anesthesia.
- D. Avoid drinking fluids after the procedure.
Correct Answer: A
Rationale: Removing all metal objects is essential for safety during an MRI, as magnetic fields can interact with metal.