Nokea
A nurse is collecting data from a client who has thrombocytopenia. The nurse should identify which of the following findings increases the client's risk for injury.
- A. Wears a face mask around others
- B. Sleeps 8 to 10 hr per night
- C. Uses a firm bristled toothbrush
- D. Increased intake of green, leafy vegetables
Correct Answer: C
Rationale: A firm-bristled toothbrush risks gum bleeding in thrombocytopenia. Masks, sleep, or vegetables don't increase injury risk.
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A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I should keep my baby rear-facing in the car seat until she is 2 years old.
- B. I should position the car seat's retainer clip at the level of my baby's belly button.
- C. I should place my baby in the car seat at a 90-degree angle.
- D. I should enable the airbag when my baby is in the front seat of the car.
Correct Answer: A
Rationale: Rear-facing until age 2 maximizes safety per AAP guidelines. The retainer clip should be at armpit level, the angle at 45°, and airbags off for front-seat safety.
A nurse is reinforcing teaching with a client who has a new prescription for omeprazole. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication at bedtime.
- B. I might need to take this medication for several weeks.
- C. I can take this medication with an antacid if I have heartburn.
- D. I should stop taking this medication if I feel better.
Correct Answer: B
Rationale: Omeprazole often requires weeks of treatment for full effect, showing understanding. It's taken before meals, antacids don't enhance it, and stopping early risks relapse.
A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy. The nurse should explain to the client which of the following adverse reactions can occur following the procedure.
- A. Tingling of the scalp
- B. Voice alteration
- C. Neck pain
- D. Temporary memory loss
Correct Answer: D
Rationale: Temporary memory loss is a common side effect of ECT, often resolving post-treatment. Tingling, voice changes, or neck pain are not typically associated with ECT.
A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?
- A. Administer aspirin if the client develops a fever.
- B. Initiate contact precautions for the client.
- C. Assign the client to a negative-pressure airflow room.
- D. Have visitors remain at least 0.91 m (3 feet. away from the client.
Correct Answer: C
Rationale: Varicella requires airborne precautions, including a negative-pressure room, to prevent spread. Aspirin risks Reye's syndrome, contact precautions alone are insufficient, and distance doesn't replace airborne measures.
A nurse is caring for a client who is postoperative following an appendectomy. Which of the following findings should the nurse report to the provider?
- A. The client reports pain at the incision site.
- B. The client's temperature is 38.1°C (100.5°F).
- C. The client has not had a bowel movement since surgery.
- D. The client's incision is intact with minimal drainage.
Correct Answer: B
Rationale: A temperature of 38.1°C suggests possible infection, requiring reporting. Pain, no bowel movement, or minimal drainage are expected post-appendectomy.