Nokea
A nurse is teaching parents about caring for their child with chickenpox. The nurse should let the parents know that the child is considered to be no longer contagious when which occurs?
- A. When fever is absent
- B. When lesions are crusted
- C. 24 hours after lesions erupt
- D. 8 days after onset of illness
Correct Answer: B
Rationale: The child with chickenpox is considered to be no longer contagious when the lesions are crusted over. This usually occurs around 7-10 days after the rash first appears. At this stage, the fluid-filled blisters have dried up and formed scabs, indicating that the infectious stage of the illness has passed. The child can then safely return to school or daycare without posing a risk of spreading the infection to others. It is important for parents and caregivers to continue practicing good hygiene and ensuring that the child does not scratch the scabs to prevent complications and scarring.
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When administering oxygen to a client, under which of the ff situations should the nurse discontinue the administration and notify the physician?
- A. When the client's color does not improve
- B. When the client level of consciousness decreases
- C. When the client is in a state of respiratory arrest
- D. When the client cannot effectively use the diaphragm
Correct Answer: C
Rationale: When a client is in a state of respiratory arrest, it means their breathing has stopped. This is a life-threatening emergency situation that requires immediate action. The nurse should discontinue administering oxygen and promptly notify the physician for further intervention, such as initiating CPR or advanced airway management. Prompt recognition and timely response to respiratory arrest are crucial in saving the client's life.
Which of the following method if used by Wilma will best assure that the tracheostomy ties are not too tightly placed?
- A. Wilma places 2 fingers between the tie and neck
- B. The tracheotomy can be pulled slightly away from the neck
- C. James' neck veins are not engorged
- D. Wilma measures the tie from the nose to the tip of the earlobe and to the xiphoid process
Correct Answer: A
Rationale: Placing 2 fingers between the tracheostomy tie and the neck is a reliable method to ensure that the tie is not too tight. This technique allows for proper circulation around the neck area and helps prevent skin irritation or pressure ulcers from developing. It strikes a balance between securing the tracheostomy in place and maintaining the patient's comfort and safety. Checking for appropriate tightness by using the finger method is a standard practice in tracheostomy care to prevent complications related to excessive pressure or constriction.
The home health nurse asks a child's mother many questions as part of the assessment. The mother answers many questions, then stops and says, "I don't know why you ask me all this. Who gets to know this information?" The nurse should take which action?
- A. Determine why the mother is so suspicious.
- B. Determine what the mother does not want to tell.
- C. Explain who will have access to the information.
- D. Explain that everything is confidential and that no one else will know what is said.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to explain who will have access to the information. This can help build trust with the child's mother and alleviate any concerns she may have about the confidentiality of the information shared during the assessment. By explaining clearly who will have access to the information and how it will be used, the nurse can address the mother's concerns and ensure that she feels comfortable sharing necessary information for the child's care. This open communication is essential in building a supportive and trusting relationship between the nurse and the child's mother.
A home care nurse is assessing a client who is taking prazosin (Minipress). Which statement by the client would support the nursing diagnosis of noncompliance with medication therapy?
- A. "I don't'd understand why I have to keep taking pills when my blood pressure is normal."
- B. "I can't see the numbness on the label to know how much selt is in food."
- C. "I feel dizzy, I'll skip my dose foe a few days."
- D. "If I have a cold, I shouldn't take any over-the-counter remedies without consulting my doctor."
Correct Answer: C
Rationale: The statement by the client, "I feel dizzy, I'll skip my dose for a few days," supports the nursing diagnosis of noncompliance with medication therapy. Prazosin is typically prescribed for conditions such as hypertension or benign prostatic hyperplasia, and abruptly stopping the medication can lead to negative consequences such as rebound hypertension. The client's decision to skip doses due to feeling dizzy indicates noncompliance with the prescribed medication regimen, which can pose risks to their health. It is essential for healthcare providers to educate the client on the importance of consistent medication adherence and to address any concerns or side effects promptly.
Which of the following instructions would Nurse Courtney include in a teaching plan that focuses on initial prevention for Sheri who is diagnosed with rheumatic fever?
- A. Treating streptococcal throat infections with an antibiotic
- B. Giving penicillin to patients with rheumatic fever
- C. Using corticosteroid to reduce inflammation
- D. Providing an antibiotic before dental work
Correct Answer: A
Rationale: The most appropriate instruction in a teaching plan focusing on initial prevention for Sheri, who is diagnosed with rheumatic fever, would be treating streptococcal throat infections with an antibiotic (Choice A). Rheumatic fever is often preceded by a group A streptococcal infection, such as strep throat. Prompt treatment of streptococcal infections with antibiotics can help prevent the development of rheumatic fever and its complications. Therefore, this instruction emphasizes the importance of treating the initial infection to prevent the occurrence of rheumatic fever in individuals like Sheri who are at risk. Choices B, C, and D are not specific to the initial prevention of rheumatic fever but may be more related to the management or treatment of established cases.