Nokea
A nursing assistant is taking care of a child in the arm restraint shown below. To provide care for this child, what should the assistant do?
- A. Unpin the restraint and perform range-ofmotion exercises.
- B. Unwrap the restraint and bathe the arm using warm water
- C. Leave the restraint in its current position.
- D. Remove one tape at a time while bathing the child’s arm.
Correct Answer: C
Rationale: The restraint should remain in position. Removing the restraint or untaping the restraint will risk dislodging the I.V.
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A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
- A. The neonate will be suctioned.
- B. The neonate will be dried and stimulated.
- C. The neonate will be given oxygen.
- D. The neonate's umbilical cord will be cut.
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
For the client with a substance abuse problem, which of the following would be most helpful to aid the client in dealing with feelings and concerns related to alcohol and drugs?
- A. Individual therapy.
- B. Group sessions.
- C. Solitary activities.
- D. Recreation.
Correct Answer: B
Rationale: Group sessions provide peer support and shared experiences, highly effective for addressing feelings related to substance abuse.
A client with a history of multiple sclerosis is prescribed interferon beta-1a (Avonex). The nurse should instruct the client to report which of the following side effects immediately?
- A. Flu-like symptoms.
- B. Depression.
- C. Fatigue.
- D. Injection site redness.
Correct Answer: B
Rationale: Depression is a serious side effect of interferon beta-1a, requiring immediate reporting due to the risk of worsening mental health.
A client with a history of breast cancer is admitted with bone metastases. The nurse should include which of the following in the plan of care?
- A. Administer bisphosphonates as prescribed.
- B. Restrict calcium intake.
- C. Encourage bed rest.
- D. Apply cold packs to affected areas.
Correct Answer: A
Rationale: Bisphosphonates reduce bone resorption and pain in bone metastases.
The client scheduled for a transurethral resection prostatectomy (TURP) asks the nurse to explain how the prostate is going to be removed. The nurse should tell the client that the prostate will be removed through which pathway?
- A. The urethra
- B. A lower abdominal incision
- C. An upper abdominal incision
- D. An incision made in the perineal area
Correct Answer: A
Rationale: A TURP is done through the urethra. An instrument called a resectoscope is used to remove the tissue using high-frequency current. A lower abdominal incision is used for suprapubic or retropubic prostatectomy. An upper abdominal incision is not used. An incision between the scrotum and anus is made when a perineal prostatectomy is performed.