Nokea
An adolescent girl calls the nurse at the clinic because she had unprotected sex the night before and does not want to be pregnant. What should the nurse explain to the girl?
- A. It is too late to prevent an unwanted pregnancy
- B. An abortion may be the best option if she is pregnant
- C. Norplant can be administered to prevent pregnancy for up to 5 years
- D. Postcoital contraception is available to prevent implantation
Correct Answer: D
Rationale: In this scenario, the most appropriate option for the nurse to explain to the adolescent girl is postcoital contraception, also known as emergency contraception or the morning-after pill. Postcoital contraception is a method used to prevent pregnancy after unprotected sex or contraceptive failure. It works by preventing or delaying ovulation, inhibiting fertilization, or preventing implantation of a fertilized egg in the uterus.
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Which is the most appropriate nursing intervention for the newborn who is jittery and twitching and has a high-pitched cry?
- A. Monitor blood pressure closely.
- B. Obtain urine sample to detect glycosuria.
- C. Obtain serum glucose and serum calcium levels.
- D. Administer oral glucose or, if newborn refuses to suck, IV dextrose.
Correct Answer: C
Rationale: The most appropriate nursing intervention for the jittery and twitching newborn with a high-pitched cry is to obtain serum glucose and serum calcium levels (Option C). These symptoms are indicative of possible hypoglycemia or hypocalcemia, which are common issues for newborns. Monitoring glucose and calcium levels will help identify and address any imbalances that may be causing these symptoms. Administering glucose (Option D) may be necessary if hypoglycemia is confirmed, but it should be based on the results of blood tests. Monitoring blood pressure (Option A) and obtaining a urine sample to detect glycosuria (Option B) are not the priority interventions in this scenario compared to assessing serum glucose and calcium levels.
Nurse Analiza is administering a medication via the intraosseous route to a child. Intraosseous drug administration is typically used when a child is:
- A. Under age 3
- B. Over age 3
- C. Critically ill and under age 3
- D. Critically ill and over age 3
Correct Answer: C
Rationale: Intraosseous drug administration is typically reserved for pediatric patients who are critically ill and under the age of 3. This route is chosen when intravenous access cannot be readily established or when the patient is in urgent need of medication administration. Young children have easily accessible bone marrow spaces, making intraosseous administration a quick and effective means of delivering medications in emergency situations. Older children tend to have more developed vasculature, making it easier to establish intravenous access in those cases.
Which should the nurse recommend for the diet of a child with chronic renal failure?
- A. High in protein
- B. Low in vitamin D
- C. Low in phosphorus
- D. Supplemented with vitamins A, E, and K
Correct Answer: C
Rationale: For a child with chronic renal failure, it is important to recommend a diet that is low in phosphorus. In chronic renal failure, the kidneys have difficulty filtering phosphorus from the blood, leading to high levels of phosphorus in the body. High phosphorus levels can contribute to bone problems and other complications in renal failure patients. By recommending a diet low in phosphorus, the nurse can help manage the child's condition and reduce the risk of further complications. It is also important to monitor other electrolyte levels such as calcium, potassium, and sodium, and adjust the diet accordingly to maintain proper balance.
During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?
- A. "The head of your bed must remain flat for 24 hours after surgery."
- B. "You should avoid deep breathing and coughing after surgery."
- C. "You won't be able to swallow for the first day or two."
- D. "You must avoid hyperextending your neck after surgery."
Correct Answer: D
Rationale: The correct statement to include during preoperative teaching for a client undergoing subtotal thyroidectomy is "You must avoid hyperextending your neck after surgery." This is important because hyperextending the neck can put strain on the suture line and may lead to dehiscence (wound opening). It is crucial for the client to avoid any activities or positions that could compromise the surgical site and hinder proper healing.
A man with a history of diabetes and chronic lung disease is admitted to the hospital with prostate cancer. He has all the following symptoms. Which should the nurse address first?
- A. Fever of 38.3 Celsius
- B. Difficulty urinating
- C. Respiratory rte 36/min
- D. Painful legs and feet
Correct Answer: C
Rationale: In this case, the nurse should address the respiratory rate of 36 breaths per minute first, as it indicates potential respiratory distress in a patient with chronic lung disease. Rapid and shallow breathing could be a sign of worsening lung function or complications such as pneumonia, which require immediate attention to ensure adequate oxygenation and prevent further deterioration. Monitoring and addressing the patient's respiratory status are crucial in preventing respiratory failure and other serious complications.