Nokea
A nurse is collecting data from the mother of a toddler. Which of the following activities should the nurse expect the toddler to be able to perform?
- A. Jump rope
- B. Ride a tricycle
- C. Print letters and numbers
- D. Use scissors to cut out a picture
Correct Answer: B
Rationale: The correct answer is B: Ride a tricycle. Toddlers typically develop gross motor skills around 2 years old, making riding a tricycle a suitable activity. Jumping rope (choice A) requires more advanced coordination and balance. Printing letters and numbers (choice C) involves fine motor skills that develop later. Using scissors (choice D) also requires more advanced fine motor skills.
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A nurse at a community-based health fair is promoting having a routine Papanicolaou test (Pap smear) to young adult women. Which of the following types of preventive care is the Pap smear?
- A. Primary level
- B. Secondary level
- C. Tertiary level
- D. Self-care ability level.
Correct Answer: B
Rationale: The correct answer is B: Secondary level preventive care. A Pap smear is a screening test that aims to detect precancerous or cancerous cells in the cervix at an early stage. This type of preventive care falls under secondary prevention because it focuses on early detection and treatment of disease before it progresses. Primary prevention (choice A) aims to prevent the disease from occurring in the first place. Tertiary prevention (choice C) focuses on managing and reducing the impact of the disease after it has already developed. Self-care ability level (choice D) is not a recognized level of preventive care.
A nurse is administering a tap-water enema to a client. The client reports cramping as the nurse instills the irrigating solution. Which of the following actions should the nurse take to relieve the client's discomfort?
- A. Lower the height of the solution container.
- B. Encourage the client to bear down.
- C. Allow the client to expel some fluid before continuing.
- D. Stop the enema and document that the client did not tolerate the procedure.
Correct Answer: A
Rationale: Correct Answer: A: Lower the height of the solution container.
Rationale: Lowering the height of the solution container will decrease the rate of flow, reducing the pressure and volume of the solution entering the client's colon. This can help alleviate the cramping sensation by slowing down the administration of the enema.
Summary of other choices:
B: Encouraging the client to bear down may increase intra-abdominal pressure, worsening the cramping sensation.
C: Allowing the client to expel some fluid before continuing may not address the root cause of the discomfort, which is the rapid influx of solution.
D: Stopping the enema and documenting that the client did not tolerate the procedure does not actively address the client's discomfort or provide immediate relief.
A nurse is caring for a client whose hysterectomy wound has eviscerated. Which of the following actions should the nurse take?
- A. Assure the client that this is an expected occurrence after surgery.
- B. Apply an abdominal binder to the wound area.
- C. Turn the client onto her side.
- D. Cover the wound with a moist sterile dressing.
Correct Answer: D
Rationale: The correct action is to cover the wound with a moist sterile dressing (choice D). This helps to maintain a moist environment for wound healing and prevents infection. Assuring the client that evisceration is expected (choice A) is incorrect and can cause distress. Applying an abdominal binder (choice B) can increase pressure on the wound and worsen the evisceration. Turning the client onto her side (choice C) is not recommended as the eviscerated wound needs immediate attention. Overall, choice D is the most appropriate immediate action to protect the wound and promote healing.
A nurse is caring for a client who has hemophilia and has developed hemarthrosis of the left knee. Which of the following actions should the nurse take?
- A. Administer low-dose aspirin.
- B. Apply heat to the knee.
- C. Administer analgesics IM.
- D. Elevate the knee.
Correct Answer: D
Rationale: The correct answer is D: Elevate the knee. Elevating the knee helps reduce swelling and promote venous return, which can help alleviate pain and prevent further bleeding in hemarthrosis. Administering low-dose aspirin (A) is contraindicated in hemophilia as it can increase the risk of bleeding. Applying heat (B) can exacerbate bleeding by increasing blood flow to the area. Administering analgesics IM (C) may provide pain relief but does not address the underlying issue of bleeding.
A nurse is observing the IV catheter insertion site of a client who is receiving continuous IV therapy. Which of the following manifestations should the nurse identify as an indication that the client has developed phlebitis?
- A. Erythema
- B. Pallor
- C. Coolness
- D. Drainage
Correct Answer: A
Rationale: The correct answer is A: Erythema. Phlebitis is inflammation of the vein, which commonly presents with redness (erythema) at the site. This is due to the body's response to the irritation caused by the IV catheter. Pallor (choice B) and coolness (choice C) are not typical signs of phlebitis, as they suggest decreased blood flow rather than inflammation. Drainage (choice D) may indicate an infection but is not specific to phlebitis. In summary, erythema is the key indicator of phlebitis due to the inflammatory response in the vein.