Nokea
An 18-month-old is scheduled for a cleft palate repair. The usual type of restraints for the child with a cleft palate repair are:
- A. Elbow restraints
- B. Full arm restraints
- C. Wrist restraints
- D. Mummy restraints
Correct Answer: A
Rationale: Elbow restraints are used post-cleft palate repair to prevent an 18-month-old from touching the surgical site, protecting sutures without overly restricting movement. Full arm or wrist restraints are excessive, while mummy restraints are impractical and unnecessary. Nurses apply these to balance safety and comfort, educating parents on their temporary use to ensure healing, critical for speech and feeding outcomes.
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After having an I.V. line in place for 72 hours, a patient complains of tenderness, burning, and swelling. Assessment of the I.V. site reveals that it is warm and erythematous. This usually indicates:
- A. Infection
- B. Infiltration
- C. Phlebitis
- D. Bleeding
Correct Answer: C
Rationale: These symptoms indicate phlebitis, inflammation of the vein.
Which of the following is known to have a role in wound healing?
- A. Vitamin A
- B. Vitamin K
- C. Vitamin C
- D. Vitamin B complex
Correct Answer: C
Rationale: Vitamin C is essential for collagen synthesis, a key wound healing component, strengthening tissue repair. Vitamin A supports epithelial growth, Vitamin K aids clotting, and B complex boosts energy, but collagen formation is primary. Nurses ensure adequate C intake (e.g., citrus), accelerating recovery, preventing dehiscence, and supporting immune response at wound sites.
Five teaspoons is equivalent to how many milliliters (ml)?
- A. 30 ml
- B. 25 ml
- C. 12 ml
- D. 22 ml
Correct Answer: B
Rationale: One teaspoon equals 5 ml, so 5 teaspoons is 25 ml.
A client has a new diagnosis of nephrotic syndrome, and the nurse is providing dietary management education. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of high-sodium foods.
- B. You should decrease your intake of high-sodium foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of dairy products.
Correct Answer: B
Rationale: For a client with nephrotic syndrome, decreasing the intake of high-sodium foods is essential to manage fluid retention and symptoms of the condition. Excessive sodium can lead to fluid retention, swelling, and worsen the condition. Therefore, advising the client to decrease their high-sodium food intake aligns with the dietary management approach to help control nephrotic syndrome. Choices A, C, and D are incorrect. Increasing high-sodium foods would exacerbate fluid retention, avoiding lactose is not specifically required for nephrotic syndrome, and increasing dairy products may not be necessary unless individualized based on the client's needs and lab values.
The nurse is suctioning a client through a tracheal tube. During the procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?
- A. Notify the registered nurse immediately.
- B. Stop the procedure and oxygenate the client.
- C. Continue to suction the client at a quicker pace.
- D. Ensure that the suction is limited to 15 seconds.
Correct Answer: B
Rationale: A 10-beat heart rate drop during suctioning suggests vagal stimulation or hypoxia; stopping the procedure and oxygenating (B) is the next action to reverse this. Notifying the RN (A) or limiting time (D) follows. Continuing (C) risks worsening. B is correct. Rationale: Suctioning can trigger bradycardia via vagal nerve activation or oxygen depletion; halting and oxygenating restores stability, a critical step per airway management guidelines, preventing further cardiac compromise.