Nokea
After a cleft lip repair, the nurse instructs the parents about cleaning of the lip repair site. The nurse should plan to use which solution when demonstrating this procedure to the parents?
- A. Tap water
- B. Sterile water
- C. Full-strength hydrogen peroxide
- D. Half-strength hydrogen peroxide
Correct Answer: B
Rationale: After cleft lip repair, the site is cleansed with sterile water using a cotton swab after feeding and as prescribed. Agency procedure should also be followed. The parents should be instructed to use a rolling motion starting at the suture line and rolling out. Tap water is not a sterile solution. Hydrogen peroxide may disrupt the integrity of the site.
You may also like to solve these questions
A client diagnosed with type 2 diabetes mellitus is being discharged from the hospital after an occurrence of hyperglycemic hyperosmolar state (HHS). The nurse creates a discharge teaching plan for the client and identifies which intervention as a priority?
- A. Exercise routines
- B. Controlling dietary intake
- C. Keeping follow-up appointments
- D. Monitoring for signs/symptoms of dehydration
Correct Answer: D
Rationale: Monitoring for dehydration is the priority for HHS, as it can progress rapidly and is life-threatening. Exercise, diet, and follow-up are important but secondary to preventing dehydration-related complications.
The home care nurse visits a client who was recently diagnosed with cirrhosis and provides home care management instructions to the client. Which statement by the client indicates the need for further teaching?
- A. I will obtain adequate rest.
- B. I should monitor my weight regularly.
- C. I will take Tylenol if I get a headache.
- D. I should include sufficient carbohydrates in my diet.
Correct Answer: C
Rationale: Cirrhosis is a chronic liver disease, and acetaminophen (Tylenol) should be avoided because it can cause fatal liver damage in clients with cirrhosis. Adequate rest, regular weight monitoring, and sufficient carbohydrate intake (2000 to 3000 calories daily) are appropriate for managing cirrhosis.
Which instruction should the nurse include in the teaching plan for a client taking iron supplements to correct iron deficiency anemia?
- A. Eat a low-fiber diet.
- B. Limit the intake of fluids.
- C. Limit the intake of meat, fish, and poultry.
- D. Avoid taking the iron supplements with milk or antacids.
Correct Answer: D
Rationale: The client should avoid taking the iron supplements with milk or antacids because these items decrease the absorption of iron. The client should also avoid taking the iron with food, if possible. Finally, the client should take in sufficient fiber and fluids to prevent constipation as a side effect of iron therapy. The client should increase the intake of natural sources of iron, such as meats, fish, and poultry.
The nurse is working with a client who has just been diagnosed with pancreatic cancer. The client says, 'I have so much left to do. I'm too young to die like this.' Which of the following stages of Kübler-Ross's five stages of grieving does the nurse recognize in this client?
- A. anger
- B. denial
- C. bargaining
- D. acceptance
- E. depression
Correct Answer: C
Rationale: The client's statement reflects bargaining, expressing a desire to delay death to accomplish more.
A nurse is preparing staff education on the developmental stages and milestones in a normally developing fetus. Which information should be included?
- A. The testes at the inguinal ring descend to scrotum at 12 weeks.
- B. The bladder and urethra separate from the rectum at 12 weeks.
- C. The kidneys are in position at 16 weeks with typical shape and plan.
- D. The nostrils reopen and primitive respiratory-like movement begins at 24 weeks.
Correct Answer: C
Rationale: Kidneys reach their position by 16 weeks. Testicular descent occurs later (28-32 weeks), bladder-urethra separation by 8 weeks, and respiratory movements by 20-24 weeks.