Nokea
Before administering eardrops to a toddler,the nurse should recognize that it is essential to consider which of the following?
- A. Age
- B. Weight
- C. Developmental level
- D. Ability to understand
Correct Answer: C
Rationale: The toddler’s developmental level affects cooperation and ability to follow instructions during eardrop administration. Age is a factor but less specific and weight or understanding are secondary to developmental considerations.
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The nurse is suctioning the tracheostomy of an adult client. The recommended pressure setting for performing tracheostomy suctioning on the adult client is:
- A. 40-60 mmHg
- B. 60-80 mmHg
- C. 80-120 mmHg
- D. 120-140 mmHg
Correct Answer: C
Rationale: Recommended suction pressure for adult tracheostomy is 80-120 mmHg to effectively remove secretions without causing trauma. Higher or lower pressures are less safe or effective.
The nurse is caring for an older client hospitalized with dehydration. Which site should be used to check for skin turgor?
- A. Hand
- B. Arm
- C. Abdomen
- D. Forehead
Correct Answer: C
Rationale: In older adults the abdomen is the most reliable site for assessing skin turgor due to age-related changes in skin elasticity on the hands and arms. The forehead is not a standard site for this assessment.
A client who has gout is most likely to form which type of renal calculi?
- A. Struvite stones
- B. Staghorn calculi
- C. Uric acid stones
- D. Calcium stones
Correct Answer: C
Rationale: The presence of urinary tract infection is a factor in the formation of struvite stones. Staghorn calculi is the other name for struvite stones associated with urinary tract infection. Clients who have gout form uric acid stones. Clients who have increased urinary excretion of calcium form calcium stones.
A 30-year-old client has just been treated in the ER for bruises and abrasions to her face and a broken arm from domestic violence, which has been increasing in frequency and intensity over the last few months. The nurse assesses her as being very anxious, fearful, bewildered, and feeling helpless as she states, 'I don't know what to do, I'm afraid to go home.' The best response by the nurse to the client would be:
- A. I wouldn't want to go home either; call a friend who could help you.
- B. Did you do something that could have made him so angry?
- C. Let's talk about people and resources available to you so that you don't have to go home.
- D. I'll call the police and they will take care of him, and you can go home and get some rest.
Correct Answer: C
Rationale: A person in crisis needs support, assistance, and direction from a caregiver rather than just an instruction. A battered person may feel guilt and think that they cause the abuser's behavior; however, the abuser has the problem and goes through phases of violence. The nurse should provide support and guidance to the client in crisis by offering alternatives and assist in referrals. Focusing on help from law enforcement may be a very temporary solution, because the victim may be fearful of pressing charges. This answer does not address the crisis of going home.
Which of the following is an expected finding in a child with osteogenesis imperfecta?
- A. Blue sclera
- B. Hutchinson's teeth
- C. Anisocoria
- D. Pectus excavatum
Correct Answer: A
Rationale: Blue sclera is a hallmark of osteogenesis imperfecta due to thin connective tissue in the eyes. Hutchinson’s teeth are associated with congenital syphilis anisocoria is unequal pupil size and pectus excavatum is a chest deformity not specific to this condition.