Nokea
A nurse is teaching parents about reducing lead exposure in their home. Which of the following should be included?
- A. Use only bottled water for drinking.
- B. Remove all carpeting from the home.
- C. Regularly wet-mop floors and surfaces.
- D. Replace all windows with new ones.
Correct Answer: C
Rationale: Wet-mopping reduces lead dust, a common exposure source. Bottled water is unnecessary unless water is contaminated, carpeting removal is excessive, and window replacement is costly and not always needed.
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After a tonsillectomy and adenoidectomy, which of the following findings should alert the nurse to suspect early hemorrhage in a 5-year-old child?
- A. Drooling of bright red secretions.
- B. Pulse rate of 95 bpm.
- C. Vomiting of 25 mL of dark brown emesis.
- D. Blood pressure of 95/56 mm Hg.
Correct Answer: A
Rationale: Drooling of bright red secretions indicates active bleeding, a sign of early hemorrhage post-tonsillectomy. A pulse rate of 95 bpm is within normal range for a 5-year-old, and vomiting dark brown emesis suggests older blood, not active bleeding. Blood pressure of 95/56 mm Hg is low but not specific to hemorrhage without other signs.
When planning a visit to the parents of an infant who died of sudden infant death syndrome (SIDS) at home, the nurse should visit the parents at which of the following times?
- A. A few days after the funeral.
- B. Two weeks after the funeral.
- C. As soon as the parents are ready to talk.
- D. As soon after the infant's death as possible.
Correct Answer: C
Rationale: Visiting as soon as the parents are ready to talk respects their grieving process and ensures they are emotionally prepared to receive support.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, which of the following descriptions about the stoma's appearance should the nurse include in the teaching?
- A. Becoming dark brown in 2 months.
- B. Appearing moist and pink to red.
- C. Drying out within a few weeks.
- D. Shrinking significantly in size.
Correct Answer: B
Rationale: A healthy stoma is moist and pink to red, indicating good blood supply.
The parents of an 18-year-old preparing to enter college ask if their daughter should have the meningococcal (MCV4) vaccine. The nurse should tell the parents:
- A. It is only necessary to have the vaccine if your daughter will be living in a dormitory.'
- B. We recommend the vaccine, but it needs to be given as a series of three injections.'
- C. Let's review your records. The vaccine may have already been given a few years ago.'
- D. We highly recommend this vaccine, but we will need to do a pregnancy screening first.'
Correct Answer: C
Rationale: Checking vaccination records confirms whether the MCV4 vaccine, recommended for adolescents, was previously administered.
A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for pain 4 hours later, his mother leaves the room and the child begins to cry. The nurse's initial assessment of the child's pain is that he is:
- A. Not in pain because the crying began after the mother leaves.
- B. Less tolerant of pain because he is upset.
- C. In pain because he is crying.
- D. Not in pain because he was medicated 4 hours ago.
Correct Answer: B
Rationale: Emotional distress, such as the mother leaving, can lower pain tolerance, making the child more sensitive to existing pain.