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. Ensure that area rugs have rubber backs.
- C. Mark the edges of the doorway to the house with tape.
- D. Place a throw rug over electrical cords.
Correct Answer: B
Rationale: The correct answer is B: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, especially for an older adult recovering from knee replacement surgery. Rubber-backed rugs provide traction and stability, reducing the risk of accidents. Encouraging the client to avoid wearing shoes at home (A) may increase the risk of slipping on smooth surfaces. Marking the edges of the doorway with tape (C) may not be effective and could create a tripping hazard. Placing a throw rug over electrical cords (D) is unsafe as it can cause the older adult to trip.
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A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the head of the bed at a 30° angle.
- B. Offer sips of water due to having surgery.
- C. Log roll the adolescent every 2 hours.
- D. Assist the adolescent to ambulate 12 hours following surgery.
Correct Answer: C
Rationale: The correct answer is C: Log roll the adolescent every 2 hours. This is important to prevent pressure ulcers and maintain spinal alignment post-surgery. Log-rolling involves turning the patient as a unit to avoid twisting the spine. Maintaining the head of the bed at a 30° angle (choice A) is important for respiratory function but not specific to spinal surgery. Offering sips of water (choice B) is generally appropriate after surgery but not specific to spinal instrumentation. Assisting the adolescent to ambulate (choice D) should be done gradually and with caution, typically starting with sitting on the bedside first, rather than a fixed time frame like 12 hours post-surgery.
A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
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 assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Fever
- B. Steatorrhea
- C. Tinnitus
- D. Dysphagia
Correct Answer: A
Rationale: The correct answer is A: Fever. Bacterial pneumonia commonly presents with fever due to the body's immune response to the infection. This is a classic sign of inflammation caused by the bacterial infection in the lungs. Steatorrhea (B), tinnitus (C), and dysphagia (D) are not typical manifestations of bacterial pneumonia. Steatorrhea is associated with malabsorption disorders, tinnitus is often related to ear issues, and dysphagia is difficulty swallowing, which is not a common symptom of pneumonia. Therefore, the nurse should expect fever as a key manifestation of bacterial pneumonia in the child.
The nurse is continuing to care for the child. Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: A,B,F
Rationale: The correct answers are A, B, and F. A) Reviewing cast care instructions with the child's parents ensures proper care at home. B) Administering ibuprofen helps manage pain and inflammation. F) Elevating the affected forearm reduces swelling. Choices C, D, and E are incorrect because C) placing a nonadherent dressing is not a priority over cast care, D) explaining cast application to the child is not essential for ongoing care, and E) applying ice packs to fingers and forearm is not as crucial as administering pain relief and elevating the affected area.