Nokea
A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
- A. Thoroughly explain each procedure to the toddler.
- B. Start the examination with routine immunizations.
- C. Allow the toddler to handle the equipment.
- D. Completely undress the toddler.
Correct Answer: C
Rationale: Allowing the toddler to handle equipment reduces fear and increases cooperation.
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A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
- A. Inject 15 units of air into the regular insulin vial.
- B. Withdraw 10 units of NPH insulin.
- C. Verify the dosage with another nurse.
- D. Place the cap over the needle.
Correct Answer: A
Rationale: Injecting air into the regular insulin vial next follows the correct sequence for mixing insulins.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.
A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
- A. Memory loss that disrupts ADLs
- B. Acute onset of confusion
- C. Illusions
- D. Catatonia
Correct Answer: A
Rationale: Memory loss disrupting ADLs is a hallmark of dementia.
A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.
A nurse is contributing to the plan of care for a client who is experiencing a herpes simplex outbreak. Which of the following interventions should the nurse recommend?
- A. Administer an antibiotic medication.
- B. Cleanse skin eruptions with povidone-iodine.
- C. Avoid over-the-counter topical ointments.
- D. Place disposable thermometers in the client's room.
Correct Answer: C
Rationale: Avoiding OTC ointments prevents irritation or delayed healing in herpes simplex outbreaks.