Nokea
An 8-month-old infant is scheduled for balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding could possibly delay the procedure and should be reported?
- A. Auscultation of a loud heart murmur
- B. Infant has been npo for 4 hours
- C. Infant has polycythemia
- D. Infant has severe diaper rash
Correct Answer: D
Rationale: Severe diaper rash may increase infection risk during catheterization, potentially delaying the procedure.
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The nurse is reinforcing teaching with a client who had a total knee replacement and has a new prescription for enoxaparin. Which of the following information should the nurse reinforce?
- A. Mild bruising or redness may occur at the injection site.
- B. Eliminate green, leafy, vitamin K-rich vegetables from your diet.
- C. Black stools are a common, harmless adverse effect of the medication.
- D. Take over-the-counter medications such as ibuprofen to relieve mild discomfort.
Correct Answer: A
Rationale: Mild bruising or redness is an expected side effect of enoxaparin. Black stools indicate possible bleeding, and ibuprofen increases bleeding risk. Vitamin K restriction is not necessary.
The nurse is talking with the parent of an adolescent client who arrived at the emergency department after discovering that the client was involved in a motor vehicle collision. The parent asks about the clients condition. The client is unconscious and is currently receiving CPR. Which of the following responses would be appropriate for the nurse to make?
- A. I do not have any information about your child's condition, but you can see your child now.
- B. Your child is critically ill, and we are currently caring for your child's needs.
- C. The health care team is currently attempting to revive your child after your child's heart stopped.
- D. Only the health care provider is allowed to discuss your child's condition with you.
Correct Answer: C
Rationale: Honest, clear communication about the critical situation (CPR) is appropriate while maintaining sensitivity.
The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply.
- A. I should wash my hands before and after touching the infected area.
- B. I will clean the infected area with alcohol before applying the antibiotic ointment.
- C. I will separate my child's clothing from other laundry and wash them with hot water.
- D. My child's fingernails should be kept short and well-filed.
- E. The infection could easily spread to other children who come in contact with my child.
Correct Answer: A,C,D,E
Rationale: Hand hygiene, separating laundry, keeping nails short, and recognizing the contagious nature of impetigo are correct. Cleaning with alcohol is inappropriate as it may irritate the skin.
A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
A client is scheduled for an elective laparoscopic prostatectomy in the morning. The practical nurse should notify the registered nurse about which of the following assessment data as soon as possible before surgery?
- A. INR level
- B. platelet count
- C. hemoglobin and hematocrit levels
- D. temperature 100.4 F (38 C) with cough
Correct Answer: D
Rationale: A temperature of 100.4 F with cough suggests a possible infection, which could contraindicate surgery due to increased risk of complications.