Nokea
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.
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A nurse on the pediatric unit is admitting the child from the emergency department. For each of the assessment finding below, click to specify if the assessment finding is consistent with Kawasaki disease, scarlet fever, or rheumatic fever. Each finding may support more than 1 disease process of none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
- A. Recent diagnosis of pharyngitis.
- B. Nodules
- C. Cardiomegaly
- D. Polyarthralgia
Correct Answer: A,B,C,D
Rationale: The correct answer is .
A: Recent diagnosis of pharyngitis - Consistent with all three diseases as pharyngitis can be a symptom in Kawasaki disease, scarlet fever, and rheumatic fever.
B: Nodules - Can be seen in Kawasaki disease (cervical lymphadenopathy), scarlet fever (subcutaneous nodules), and rheumatic fever (subcutaneous nodules).
C: Cardiomegaly - Seen in Kawasaki disease (coronary artery aneurysms), scarlet fever (cardiomegaly due to myocarditis), and rheumatic fever (cardiomegaly due to carditis).
D: Polyarthralgia - Present in Kawasaki disease (arthritis), scarlet fever (arthritis), and rheumatic fever (migratory arthritis).
Therefore, all these assessment findings can be associated with Kawasaki disease, scarlet fever, and rheumatic fever.
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
- A. Perform the procedure prior to meals.
- B. Hold hand flat to perform percussions on the child.
- C. Administer a bronchodilator after the procedure.
- D. Perform the procedure twice each day.
Correct Answer: A
Rationale: The correct answer is A. Performing postural drainage prior to meals helps prevent aspiration of food or stomach contents during the procedure. Postural drainage is typically done 1-2 hours after meals to minimize the risk of aspiration. Holding the hand flat (B) is incorrect as cupped hands are used for percussion to avoid injury. Administering a bronchodilator after (C) can lead to increased mucous production. Performing the procedure twice daily (D) is generally recommended, but the timing in relation to meals is crucial.
A nurse is caring for a client in the outpatient health clinic. For each potential nursing Intervention, click to specify if the intervention is indicated or not indicated.
- A. Encourage naps during the day when client is tired.
- B. Encourage a regular sleep-wake schedule.
- C. Encourage high-calorie finger foods.
- D. Advise client to notify provider if pregnant.
- E. Instruct client to avoid foods that have been fermented or aged.
- F. Advise client to rise slowly from sitting position.
- G. Encourage client to sleep until later in the morning.
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Encouraging naps during the day when the client is tired is indicated for managing fatigue.
- Encouraging a regular sleep-wake schedule helps promote better sleep hygiene.
- Advising the client to notify the provider if pregnant is crucial for appropriate prenatal care.
- Other options are not indicated: high-calorie finger foods may not be suitable for all clients, avoiding fermented or aged foods is specific dietary advice, rising slowly is for orthostatic hypotension, and sleeping until later in the morning may disrupt the sleep-wake cycle.
A nurse is assessing a school-age child who is receiving prednisone. For which of the following adverse effects should the nurse monitor?
- A. Renal failure
- B. Stevens-Johnson syndrome
- C. Prolonged wound healing
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Prolonged wound healing. Prednisone is a corticosteroid that can suppress the immune system and delay wound healing due to its anti-inflammatory effects. The nurse should monitor for this adverse effect by assessing the child's wounds regularly for signs of slow or impaired healing. Renal failure (A) is not a common adverse effect of prednisone. Stevens-Johnson syndrome (B) is a severe skin reaction usually caused by medications but is not typically associated with prednisone. Hypotension (D) is not a common adverse effect of prednisone and is more commonly associated with other medications or conditions.
A nurse is caring for a child who has impetigo contagiosa and developed in the hospital. Which of the following actions should the nurse take?
- A. Report the infection to the state health department.
- B. Administer penicillin G, IV.
- C. Initiate contact isolation precautions.
- D. Apply a topical antifungal cream.
Correct Answer: C
Rationale: Correct Answer: C - Initiate contact isolation precautions.
Rationale: Impetigo contagiosa is highly contagious, caused by bacteria, not fungi. Contact isolation helps prevent the spread of infection. Reporting to the state health department is important, but immediate isolation is crucial. Administering penicillin G is not the first-line treatment for impetigo. Applying an antifungal cream is incorrect as impetigo is caused by bacteria, not fungi.