Nokea
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler's position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position (30°–45° elevation) promotes lung expansion and reduces the risk of airway obstruction or aspiration post-bronchoscopy. Prone (B) limits respiratory assessment, neck extension (C) risks airway obstruction, and supine (D) is less optimal for breathing.
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An infant had a repair of a myelomeningocele two days ago. Which assessment is most important to detect a problem commonly seen following myelomeningocele repair?
- A. Bowel sounds
- B. Pulse oximetry
- C. Blood pressure in all four extremities
- D. Head circumference
Correct Answer: D
Rationale: Hydrocephalus is a common complication post-myelomeningocele repair due to altered cerebrospinal fluid flow; measuring head circumference detects this by identifying increased intracranial pressure.
Which of the following terms refers to soft-tissue injury caused by blunt force?
- A. contusion
- B. strain
- C. sprain
- D. dislocation
Correct Answer: A
Rationale: A contusion is a soft-tissue injury from blunt force, causing swelling and discoloration without breaking the skin. Strains and sprains involve ligaments or muscles, and dislocation affects joints. Physiological Adaptation
A patient with a history of myocardial infarction is prescribed aspirin. Which of the following instructions should the nurse include?
- A. Take this medication on an empty stomach.
- B. Avoid taking this medication with other NSAIDs
- C. Discontinue the medication if you experience ringing in your ears.
- D. Take this medication only when you have chest pain.
Correct Answer: B
Rationale: Avoiding other NSAIDs prevents increased bleeding risk with aspirin, a key antiplatelet post-MI. Empty stomach increases GI upset, ringing requires reporting, and aspirin is daily, not PRN.
The nurse is caring for a newborn who has just been diagnosed with hypospadias. When discussing the defect with the parents, the nurse should communicate that
- A. Circumcision can be performed at any time
- B. Initial repair is delayed until 6-8 years of age
- C. Post-operative appearance will be normal
- D. Surgery will be performed in stages
Correct Answer: D
Rationale: Surgery will be performed in stages. Hypospadias correction is done in stages as soon as the infant can tolerate surgery.
The nurse is assessing a client with a history of asthma who presents with decreased breath sounds and prolonged expiration. The nurse should prioritize which of the following actions?
- A. Administer a bronchodilator as ordered.
- B. Encourage the client to cough and deep breathe.
- C. Obtain a chest X-ray.
- D. Position the client supine.
Correct Answer: A
Rationale: Decreased breath sounds and prolonged expiration indicate an asthma exacerbation with bronchoconstriction, requiring a bronchodilator to open airways. Coughing (B) is ineffective during an attack, X-rays (C) are diagnostic, and supine positioning (D) worsens breathing.