Nokea
A nurse is reinforcing preoperative teaching with an adolescent client who is scheduled for a surgical repair of scoliosis. Which of the following statements by the client indicates effectiveness of the teaching?
- A. I will not be able to walk before I go home.
- B. I will begin range-of-motion exercises on the first postoperative day.
- C. I will be discharged in 3 days.
- D. I will be fitted for my brace the day of discharge.
Correct Answer: B
Rationale: Starting range-of-motion exercises on the first postoperative day shows understanding of early mobilization. Misconceptions about walking, discharge timing, or brace fitting do not reflect accurate teaching.
You may also like to solve these questions
A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3° C (102.7° F). Which of the following actions should the nurse take to reduce the toddler's temperature?
- A. Give the toddler a tepid bath.
- B. Administer an aspirin suppository.
- C. Remove the toddler's extra clothing.
- D. Apply a cooling blanket.
Correct Answer: C
Rationale: Removing extra clothing allows heat loss safely. Tepid baths risk shivering, aspirin risks Reye's syndrome, and cooling blankets are for severe cases.
A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority?
- A. Skin turgor
- B. Potassium level
- C. Capillary refill
- D. Heart rate
Correct Answer: D
Rationale: The elevated heart rate (tachycardia) at 182/min indicates increased cardiac workload, likely due to dehydration from gastroenteritis, requiring immediate attention. While skin turgor, potassium levels, and capillary refill are important, tachycardia is the priority to stabilize the infant.
A nurse is reinforcing teaching about injury prevention with the parents of a toddler. Which of the following instructions should the nurse include in the teaching?
- A. Install window guards on windows.
- B. Place scatter rugs over hardwood floors.
- C. Keep doors locked.
- D. Supervise at playgrounds.
- E. Turn pot handles toward the front of the stove.
Correct Answer: A,C,D
Rationale: Window guards prevent falls, locked doors limit access to hazards, and supervision at playgrounds ensures safety. Scatter rugs increase tripping risks, and pot handles should face inward to prevent burns.
A nurse in a clinic is caring for a group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment?
- A. A hemangioma on the infant's torso
- B. A burn with splash marks on the lower right leg
- C. A large, irregular, brownish-blue area on the infant's buttock
- D. An abrasion on the back of the infant's arm
Correct Answer: B
Rationale: Splash-mark burns suggest possible abuse due to their pattern and should be reported. Hemangiomas are benign, bruises need context, and abrasions may be accidental.
A nurse is contributing to the plan of care for a child who has nephrotic syndrome and a prescription for corticosteroids. Which of the following interventions should the nurse recommend?
- A. Provide a low-sodium diet.
- B. Encourage increased fluid intake.
- C. Obtain urine ketone levels weekly.
- D. Administer pancreatic enzymes with each meal.
Correct Answer: A
Rationale: A low-sodium diet manages fluid retention in nephrotic syndrome. Increased fluids worsen edema, urine ketones are irrelevant, and pancreatic enzymes are not indicated.