Nokea
A three-month-old is placed in Bryant's traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for the nurse to offer the infant during hospitalization?
- A. A rattle.
- B. A stuffed animal.
- C. Colorful blocks.
- D. A tape playing nursery rhymes.
Correct Answer: A
Rationale: three-month-old can grasp a rattle
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A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
The nurse is caring for a patient hospitalized with an acute asthma attack. The nurse would be MOST concerned if which of the following was observed?
- A. The patient becomes more diaphoretic.
- B. The patient's respirations increase from 14 to 16 per minute.
- C. The patient's pulse increases from 86 to 100 beats per minute.
- D. The patient shows increasing pallor.
Correct Answer: C
Rationale: pulse increases due to decrease in oxygenation of tissues
A 19-year-old college student has a Mantoux test performed at the college health clinic. The result is positive. The clinic nurse should
- A. refer the student to an appropriate center for further testing.
- B. restrict the student's activity until his parents can be notified.
- C. notify the local Public Health Department.
- D. place the student in an isolation room in the college infirmary.
Correct Answer: A
Rationale: will perform chest x-ray
Which of the following nursing actions has the HIGHEST priority for a teenager admitted with burns to 50% of his body?
- A. Counseling regarding problems of body image.
- B. Maintain airborne precautions.
- C. Maintain aseptic technique during procedures.
- D. Encourage peers to visit on a regular basis.
Correct Answer: C
Rationale: A teenager with 50% body burns is at high risk for infection due to loss of skin barrier. Maintaining aseptic technique during procedures is the highest priority to prevent life-threatening infections. Counseling, precautions, and peer visits are important but secondary to infection control.
The nurse is caring for a client with a history of gastroesophageal reflux disease (GERD).
- A. Which instruction is most appropriate for a client with GERD?
- B. Eat large meals to reduce acid production.
- C. Lie down immediately after eating.
- D. Elevate the head of the bed during sleep.
- E. Avoid drinking water with meals.
Correct Answer: C
Rationale: Elevating the head of the bed during sleep prevents acid reflux by using gravity to keep stomach contents down. Large meals and lying down post-meal worsen reflux, and water is neutral.