Nokea
A parent asks the school nurse how to eliminate lice from their child. What is the most appropriate response by the nurse?
- A. Cut the child's hair short to remove the nits
- B. Apply warm soaks to the head twice daily
- C. Wash the child's linen and bedding in hot water
- D. Application of pediculicides
Correct Answer: D
Rationale: Application of pediculicides. Treatment of head lice consists of application of pediculicides. Pediculicides vary, and the directions must be followed carefully.
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The client is admitted with a tentative diagnosis of hepatitis. The nurse determines that which client statement would be consistent with hepatitis?
- A. "I've not been sleeping well; I've heartburn at night that wakes me."
- B. "Whenever I eat dairy products I have diarrhea for a few days."
- C. "Lately I've been short of breath when walking short distances."
- D. "I am a smoker, but lately I can't tolerate the taste of cigarettes."
Correct Answer: D
Rationale: D: Distaste for cigarettes reflects anorexia, a common hepatitis symptom. A: Heartburn suggests GERD. B: Diarrhea with dairy indicates lactose intolerance. C: Shortness of breath is unrelated to hepatitis.
A nurse is providing care to a 17 year-old client in the post-operative care unit (PACU) after an emergency appendectomy. Which finding is an early indication that the client is experiencing poor oxygenation?
- A. Abnormal breath sounds
- B. Cyanosis of the lips
- C. Increasing pulse rate
- D. Pulse oximeter reading of 92%
Correct Answer: C
Rationale: The earliest sign of poor oxygenation is an increasing pulse rate as a part of the body's compensatory mechanism. Abnormal breath sounds and cyanosis are late signs of poor oxygenation. A pulse oximetry reading of 92% is normal.
While providing home care to a client with congestive heart failure, the nurse is asked how long diuretics must be taken. What is the nurse's best response?
- A. As you urinate more, you will need less medication to control fluid.'
- B. You will have to take this medication for about a year.'
- C. The medication must be continued so the fluid problem is controlled.'
- D. Please talk to your health care provider about medications and treatments.'
Correct Answer: C
Rationale: The medication must be continued so the fluid problem is controlled.' This is the most therapeutic response and gives the client accurate information.
The client's total WBC count is 20,000/mm3 two days after surgery. Which assessment finding should the nurse most associate with this laboratory result?
- A. Respiratory rate slow and shallow
- B. Skin incision pink, crusty, and intact
- C. Dark amber urine per urinary catheter
- D. Diminished lung sounds with crackles
Correct Answer: D
Rationale: D: Elevated WBC and crackles suggest a respiratory infection. A: Slow respiration is unrelated. B: Normal incision appearance doesn't correlate. C: Amber urine indicates dehydration, not infection.
A client has returned from a cardiac catheterization. Which one of the following findings would indicate the client is experiencing a complication from the procedure?
- A. Increased blood pressure
- B. Increased heart rate
- C. Loss of pulse in the extremity
- D. Decreased urine output
Correct Answer: C
Rationale: Loss of pulse in the extremity. Loss of the pulse in the extremity would indicate impaired circulation.