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A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take.
- A. Apply pressure to the lacrimal punctum.
- B. Place the child in a sitting position.
- C. Instill the drops of medication.
- D. Pull the lower eyelid downward.
- E. Ask the child to look upward.
Correct Answer: B,C,D,E
Rationale: The correct order is B, C, D, E. First, placing the child in a sitting position ensures safety and easy access to the eyes. Next, instilling the drops of medication into the conjunctival sac is essential for proper administration. Then, pulling the lower eyelid downward helps to create a pocket for the drops to be placed. Finally, asking the child to look upward aids in the proper distribution of the medication. Choice A is incorrect as applying pressure to the lacrimal punctum is not necessary for administering eye drops. Choices F and G are not applicable in this scenario.
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A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
- A. Take pancrelipase.
- B. Complete oral hygiene.
- C. Eat a meal.
- D. Use an albuterol inhaler.
Correct Answer: D
Rationale: The correct answer is D: Use an albuterol inhaler. Prior to postural drainage, the client with cystic fibrosis should use an albuterol inhaler to help open up the airways and facilitate effective mucus clearance during the procedure. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier to breathe and improving the effectiveness of postural drainage. Pancrelipase (choice A) is taken with meals to aid in digestion, so it is not necessary before postural drainage. Completing oral hygiene (choice B) is important but not directly related to postural drainage. Eating a meal (choice C) may lead to discomfort during the procedure. The priority is to ensure clear airways with the use of the albuterol inhaler.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Apply talcum powder to the irritated area.
- B. Wipe stool from the skin using store-bought baby wipes.
- C. Apply zinc oxide ointment to the irritated area.
- D. Wipe urine from the skin using a cool cloth.
Correct Answer: C
Rationale: The correct answer is C: Apply zinc oxide ointment to the irritated area. Zinc oxide ointment provides a protective barrier on the skin, helping to soothe and heal diaper dermatitis. It also helps to keep moisture away from the irritated skin, promoting healing.
Incorrect options:
A: Applying talcum powder can further irritate the skin as it can be abrasive.
B: Store-bought baby wipes may contain chemicals or fragrances that can worsen the condition.
D: Wiping urine with a cool cloth is a good practice, but it does not address the issue of diaper dermatitis.
Overall, option C is the best choice as it directly addresses the diaper dermatitis by providing a protective barrier and promoting healing.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, as rubber-backed rugs provide better traction on smooth surfaces, reducing the risk of accidents. Placing throw rugs over electrical cords (B) can cause tripping hazards. Marking the edges of the doorway with tape (C) may not be effective and can be unsightly. Encouraging the client to avoid wearing shoes at home (A) may not directly impact safety. Overall, ensuring area rugs have rubber backs (D) is the most practical and effective approach to enhancing home safety for a postoperative older adult.
A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following activities should the nurse expect the child to participate?
- A. Using scissors to cut out paper shapes
- B. Playing with a large plastic truck
- C. Looking at alphabet flash cards
- D. Watching a cartoon in the activity room
Correct Answer: D
Rationale: The correct answer is D: Watching a cartoon in the activity room. Toddlers with acute lymphocytic leukemia are often immunocompromised, making them susceptible to infections. Therefore, activities that involve potential injury or exposure to germs, such as using scissors (choice A) or playing with toys that cannot be easily cleaned (choice B) should be avoided. Looking at alphabet flash cards (choice C) may be mentally stimulating but does not address the safety concerns. Watching a cartoon in the activity room (choice D) is a safe and enjoyable activity that can help keep the child entertained without posing a risk of injury or infection.
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Increased intracranial pressure
- C. Upper extremity hypotension
- D. Frequent nosebleeds
Correct Answer: A
Rationale: Correct Answer: A - Weak femoral pulses
Rationale: Coarctation of the aorta results in narrowing of the aorta, leading to decreased blood flow to the lower extremities. This causes weak or absent femoral pulses due to reduced blood supply. The other choices are incorrect as coarctation of the aorta typically does not directly cause increased intracranial pressure, upper extremity hypotension, or frequent nosebleeds. These symptoms are more commonly associated with other conditions such as head trauma, vascular issues, or nasal conditions.