Nokea
An adult client who has a fractured tibia is ordered to take one baby aspirin a day. He says to the nurse, 'I don't think the aspirin is doing any good. I still have pain.' What should the nurse include when replying to this client?
- A. The aspirin is given to prevent clots from forming.'
- B. The aspirin is given to keep your temperature normal.'
- C. The aspirin is given to control your pain and should be helping.'
- D. The aspirin is given to decrease inflammation at the fracture site.'
Correct Answer: A
Rationale: Low-dose aspirin is used to prevent thrombus formation in immobilized clients with fractures. It's not primarily for fever, pain, or inflammation in this context.
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The nurse is teaching a community group about how to prevent Lyme disease. What should be included in the teaching? Select all that apply.
- A. Wear dark-colored clothing when outdoors.
- B. Tuck long pants inside socks.
- C. Wear long sleeves and long pants when outside.
- D. Remove standing water.
- E. Use insect repellant containing DEET.
- F. Do not eat venison.
Correct Answer: B,C,E
Rationale: Tucking pants into socks, wearing long clothing, and using DEET repel ticks, preventing Lyme disease. Light clothing aids tick visibility, standing water is irrelevant, and venison is safe.
A patient is admitted to the hospital for a hypoglossectomy with lymph node dissection.
The patient's preoperative care includes frequent oral hygiene with hydrogen peroxide. The nurse knows the purpose of this treatment is to
- A. minimize the bacterial count in the mouth.
- B. soften the mucous membranes of the tongue before surgery.
- C. stimulate the microcirculation of the mouth.
- D. hydrate the tissues of the gums.
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to the procedure. (1) correct-destroys bacteria found in mouth, reduces the chance of infection (2) is not the action of hydrogen peroxide (3) circulation is unaffected by a mouth rinse (4) has slight drying effect on mucous membranes
A clear liquid diet is ordered for an adult following surgery. All of the following are on the client's tray. Which should be removed by the nurse?
- A. Ice cream
- B. Beef broth
- C. Apple juice
- D. Iced tea
Correct Answer: A
Rationale: Ice cream is not a clear liquid, as it contains dairy solids, and must be removed from a clear liquid diet tray.
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
- A. Transfer the client to another caregiver
- B. Reassess the goals with the client
- C. Request a longer hospital stay
- D. Role play the current plan with the client
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
- A. The newborn needs additional assessments
- B. The mother should breast feed more often
- C. A change to formula is indicated
- D. The loss is within normal limits
Correct Answer: D
Rationale: The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days post-partum because of changes in elimination and feeding.