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A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take?
- A. Apply bilateral wrist restraints.
- B. Administer opioids for pain.
- C. Implement a soft diet.
- D. Offer fluids through a straw.
Correct Answer: C
Rationale: Correct Answer: C. Implement a soft diet.
Rationale: A soft diet is appropriate post-cleft palate repair to minimize trauma to the surgical site and promote healing. It helps prevent injury and discomfort to the surgical area, allowing for adequate nutrition without causing harm.
Incorrect Choices:
A: Applying bilateral wrist restraints is unnecessary and could potentially harm the toddler, leading to increased agitation and discomfort.
B: Administering opioids for pain may not be necessary for a toddler post-cleft palate repair unless there are specific indications for severe pain.
D: Offering fluids through a straw can increase the risk of aspiration and compromise the surgical site's healing process. It is not recommended post-cleft palate repair.
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A nurse is preparing to administer 40 mg of furosemide IV. Available is furosemide 10 mg/mL. How many mL should the nurse administer per dose?
Correct Answer: 4
Rationale: Correct Answer: A nurse should administer 4 mL of furosemide per dose. To calculate this, divide the total dose (40 mg) by the concentration (10 mg/mL). 40 mg ÷ 10 mg/mL = 4 mL. This ensures the correct dosage is administered.
Choice B: Incorrect. This choice does not follow the correct calculation method and does not provide the accurate dosage.
Choice C: Incorrect. This choice does not consider the concentration of the medication and does not provide the correct amount to administer.
Choice D: Incorrect. This choice does not involve the necessary division of the total dose by the concentration, resulting in an incorrect answer.
Choice E: Incorrect. This choice does not show a clear calculation method or consideration of the medication concentration.
Choice F: Incorrect. This choice lacks any calculation or explanation, making it an insufficient answer.
Choice G: Incorrect. This choice does not provide any reasoning or calculation to support the amount to administer, making it an inadequate
A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?
- A. Dependent rubor
- B. Thick, deformed toenails
- C. Hair loss
- D. Edema
Correct Answer: D
Rationale: The correct answer is D: Edema. In chronic venous insufficiency, impaired blood flow leads to fluid accumulation in the affected limb, causing swelling or edema. This occurs due to increased venous pressure and decreased venous return. Dependent rubor (choice A) is seen in arterial insufficiency, not venous. Thick, deformed toenails (choice B) and hair loss (choice C) are not typically associated with chronic venous insufficiency. Edema is a hallmark sign due to venous stasis and capillary leakage.
A nurse is preparing to administer ciprofloxacin to a client. The nurse should identify that the medication is treatment for exposure to which of the following agents?
- A. Smallpox
- B. Anthrax
- C. Ebola virus
- D. Sarin gas
Correct Answer: B
Rationale: The correct answer is B: Anthrax. Ciprofloxacin is an antibiotic commonly used to treat anthrax, which is a bacterial infection caused by Bacillus anthracis. The rationale behind this choice is that ciprofloxacin is effective in treating anthrax infections by inhibiting the growth of the bacteria. Smallpox (A), Ebola virus (C), and Sarin gas (D) are not treated with ciprofloxacin as they are caused by a virus, a different virus, and a nerve gas, respectively.
A nurse is caring for a client who asks how albuterol helps his breathing. Which of the following responses should the nurse make? (Select all that apply)
- A. The medication will reduce inflammation.
- B. The medication will decrease coughing episodes.
- C. The medication will prevent wheezing.
- D. The medication will open the airway.
- E. The medication will stimulate the flow of mucus.
Correct Answer: C,D
Rationale: Correct Answer: C,D
Rationale:
C: The medication will prevent wheezing. Albuterol is a bronchodilator that works by relaxing the muscles in the airways, preventing and relieving wheezing.
D: The medication will open the airway. Albuterol acts by opening the airways, making it easier for the client to breathe.
Summary:
A: The medication will reduce inflammation. Albuterol does not directly reduce inflammation; it primarily works as a bronchodilator.
B: The medication will decrease coughing episodes. While albuterol may indirectly reduce coughing by improving breathing, its primary action is not to decrease coughing.
E: The medication will stimulate the flow of mucus. Albuterol does not stimulate mucus flow; it primarily works to open the airways and relieve bronchospasm.
A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
- A. Using the palm of the hand, feel for lumps using a circular motion.
- B. Expect some breast dimpling or discharge with age.
- C. Breasts can be examined in the shower with soapy hands.
- D. For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.
Correct Answer: C
Rationale: The correct answer is C: Breasts can be examined in the shower with soapy hands. This instruction is important because warm water and soap help to make the examination more comfortable and easier to detect any abnormalities. By examining the breasts in the shower, the individual can incorporate BSE into their routine without it feeling like a separate task. This method also allows for better coverage and thorough examination of the entire breast tissue.
Choice A is incorrect because using the palm of the hand in a circular motion may not be as effective in detecting lumps compared to using the fingertips. Choice B is incorrect as breast dimpling or discharge are not normal signs of aging, and should be reported to a healthcare provider. Choice D is incorrect as performing BSE at specific times in the menstrual cycle is not necessary.