Nokea
After a recent outbreak of varicella in an elementary school, the practical nurse is assisting with the development of an informative letter to parents. Which of the following instructions are appropriate to include? Select all that apply.
- A. Apply calamine lotion to soothe lesions
- B. Clip your child’s fingernails short
- C. Ensure that your child’s vaccinations are up to date
- D. Keep your child home until lesions have crusted
- E. Place mittens on your child’s hands when sleeping
Correct Answer: A,B,C,D,E
Rationale: Calamine lotion (A) relieves itching, short nails (B) and mittens (E) prevent scratching, vaccinations (C) protect against future infection, and isolation until crusted (D) prevents transmission. All are appropriate.
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A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.
- A. BP=126/68
- B. Pulse=62
- C. Respirations=8
- D. Projectile vomiting
- E. Client's skin is cool to the touch.
- F. Both pupils respond to exposure to flashlight by constricting.
Correct Answer: C,D
Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.
A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?
- A. Serum potassium
- B. Protein intake
- C. Lactose tolerance
- D. Serum albumin
Correct Answer: D
Rationale: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.
The nurse has reinforced nutritional teaching on a client with gout who is placed on a low-purine diet. Which selection by the client would indicate a need for further teaching?
- A. Broccoli
- B. An orange
- C. Chocolate cake
- D. Fish
Correct Answer: D
Rationale: Fish should be avoided on a low-purine diet. Other foods to avoid include poultry, liver, lobster, oysters, peas, spinach, and oatmeal. Answers A, B, and C are all foods included on a low-purine diet, which makes them incorrect.
A client taking Zoloft (sertraline) tells the nurse that she has also been taking St. John's wort. The nurse should report this information to the doctor because:
- A. The two substances have opposing effects.
- B. The amount of medication may be reduced.
- C. Herbals only provide a placebo effect.
- D. It will be necessary to increase the dosage.
Correct Answer: B
Rationale: St. John's wort can induce the metabolism of Zoloft, potentially reducing its effectiveness, so the doctor may need to adjust the dose. Answer A is incorrect as they do not have opposing effects. Answer C is incorrect as St. John's wort has pharmacological effects. Answer D is incorrect as increasing the dose may not be necessary.