Nokea
A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will wipe away yellow crusts that form around the incision.
- B. I will make sure that my baby's diaper is applied snugly.
- C. I will apply pressure with gauze if I see bleeding.
- D. I will apply antibiotic ointment to my baby's penis.
Correct Answer: C
Rationale: Applying pressure with gauze controls bleeding, a key aspect of Plastibell circumcision care.
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A nurse is caring for a client who has dementia. Which of the following findings should the nurse expect?
- A. Memory loss that disrupts ADLs
- B. Acute onset of confusion
- C. Illusions
- D. Catatonia
Correct Answer: A
Rationale: Memory loss disrupting ADLs is a hallmark of dementia.
The client is expressing suicidal ideations.
A nurse is collecting data from a client who is expressing suicidal ideations. Which of the following questions is the nurse's priority?
- A. Do you have a plan for harming yourself?
- B. Has anyone in your family ever died by suicide?
- C. Do you have someone to discuss your feelings with?
- D. Can you tell me about the stresses in your life?
Correct Answer: A
Rationale: Assessing a plan determines immediate risk, the priority in suicide assessment.
The client has quadriplegia.
A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?
- A. Place the client's glasses on the bedside table.
- B. Place the call light within the client's reach.
- C. Check on the client every 4 hr.
- D. Place the client in a room near the nurses' station.
Correct Answer: B
Rationale: Placing the call light within reach ensures the client can summon help.
The client is in renal failure.
A nurse is collecting data from a client who is in renal failure. Which of the following findings should the nurse identify as a manifestation of hyperkalemia?
- A. Dry mucous membranes
- B. Hyperactive reflexes
- C. Trousseau's sign
- D. Irregular heart rate
Correct Answer: D
Rationale: Irregular heart rate is a hallmark of hyperkalemia due to its effect on cardiac conduction.
A nurse is reinforcing teaching with a client who has an electrolyte imbalance. Which of the following foods should the nurse include as the lowest in potassium?
- A. Cantaloupe
- B. Orange juice
- C. Sweet potato
- D. Baked chicken breast
Correct Answer: D
Rationale: Baked chicken breast has the lowest potassium content compared to the other options, which are potassium-rich.