Nokea
After reviewing the medical orders, which of the following is essential for the nurse to assess preoperatively?
- A. The client's face for skin lesions
- B. The client of the last dose of anticoagulant
- C. The client's right eye for drainage
- D. The client's left eye for signs of strain
Correct Answer: B
Rationale: Assessing the last anticoagulant dose is critical to prevent bleeding during surgery.
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Which response demonstrates that the parents understand the nurse's explanation of why organisms travel more easily from the nasopharynx to the middle ear in a child?
- A. A child's eustachian tube is shorter and straighter.
- B. A child's eustachian tube is longer and straighter.
- C. A child's eustachian tube is longer and more curved.
Correct Answer: A
Rationale: A shorter, straighter eustachian tube in children facilitates organism travel.
The nurse is caring for the client with problems of anxiety and confusion in the critical phase of burn injury. Which interventions should the nurse implement? Select all that apply.
- A. Repeat orientation statements of person, place, and time.
- B. Turn and reposition the client at least every 2 hours.
- C. Place familiar objects from home near the client.
- D. Implement a schedule for regular sleep-wake cycles.
- E. Control distractions by keeping the room door closed.
- F. Encourage the client to write notes to family members.
Correct Answer: A,C,D
Rationale: Reiterating statements of orientation to the client decreases confusion. Familiar objects reduce anxiety when clients are in unfamiliar surroundings. Employing a regular schedule for sleep-wake cycles assists in decreasing confusion and anxiety. Turning and repositioning improves circulation and aeration but does not affect confusion. Closing the door of the room may increase client anxiety. In the acute phase of burns, the client is too ill to write notes to family members.
The nurse is discussing the prevention of herpes simplex 2. Which intervention should the nurse discuss with the client?
- A. Encourage the client to get the chickenpox immunization.
- B. Do not engage in oral sex if you have a cold sore on the mouth.
- C. Wear nonsterile gloves when cleaning the genital area.
- D. Do not share any type of towel or washcloth with another person.
Correct Answer: B
Rationale: Avoiding oral sex with a cold sore (HSV-1) prevents HSV-2 transmission to genitals. Chickenpox vaccine, gloves, and towels are unrelated.
The nurse identifies the concept of impaired skin integrity for a pediatric client diagnosed with impetigo on the arms. Which interventions should the nurse implement?
- A. Teach the parents to ensure the child takes all the prescribed antibiotics.
- B. Give the parents a written excuse so the child can go back to school.
- C. Encourage the parents to bathe the child in an oatmeal bath for the itching.
- D. Apply topical lidocaine before debriding the crusts from the lesions.
Correct Answer: A
Rationale: Completing antibiotics ensures impetigo resolution, addressing skin integrity. School return requires clearance, oatmeal baths are for comfort, and lidocaine is unnecessary.
Which question is most appropriate for the nurse to ask at this time?
- A. What childhood diseases have you had?
- B. What's your present occupation?
- C. Do you eat a well-balanced diet?
- D. How much aspirin do you take?
Correct Answer: D
Rationale: Excessive aspirin use can cause tinnitus, making it the most relevant question.