Nokea
Drag words from the choices below to fill in each blank.Nurse should anticipate a prescription for--------and-------
- A. skin traction
- B. surgical consultation
- C. pain medication
- D. limb immobilization
- E. antibiotics
- F. bed rest
Correct Answer: C,D
Rationale: Pain medication and limb immobilization are standard for managing fractures, reducing discomfort and promoting healing.
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Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer Ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: B,C,F
Rationale: Administering pain relief, protecting the abrasion, and elevating the limb reduce swelling and promote comfort.
Which of the following interventions should the nurse include in the teaching?
- A. Drink 2 liters of warm water per day.
- B. Wipe from back to front after urination.
- C. Urinate immediately after sexual intercourse.
- D. Limit fluid intake to prevent frequent urination.
Correct Answer: C
Rationale: The correct answer is C: Urinate immediately after sexual intercourse. This intervention helps prevent urinary tract infections by flushing out bacteria that may have entered the urethra during intercourse. It is important to teach this to promote urinary tract health.
A: Drinking 2 liters of warm water per day is generally good for hydration but not directly related to preventing UTIs.
B: Wiping from back to front can actually introduce bacteria from the rectal area to the urethra, increasing the risk of UTIs.
D: Limiting fluid intake to prevent frequent urination is not recommended as it can lead to dehydration and concentration of urine, potentially worsening UTIs.
In which of the following positions should the nurse place the client immediately following the procedure?
- A. Trendelenburg
- B. Prone
- C. Right lateral
- D. High-fowlers
Correct Answer: C
Rationale: The correct answer is C: Right lateral. Placing the client in the right lateral position immediately following a procedure helps prevent aspiration of secretions or blood, as gravity assists in drainage from the airway. Trendelenburg position (A) is used to increase venous return but is not appropriate post-procedure. Prone position (B) is lying face down and may obstruct airway patency. High-fowlers position (D) is sitting upright at a 90-degree angle, which is not ideal for immediate post-procedure care.
A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
After administering naloxone, which finding should the nurse expect?
- A. Somnolence
- B. Increased respiratory rate
- C. Sudden onset of pain or discomfort
- D. Hypertension and tachycardia
- E. Nausea and vomiting
Correct Answer: B
Rationale: After administering naloxone, the nurse should expect an increased respiratory rate. Naloxone is an opioid antagonist that reverses the effects of opioids, including respiratory depression. By blocking opioid receptors, naloxone can restore normal breathing patterns. Choices A (Somnolence), C (Sudden onset of pain or discomfort), D (Hypertension and tachycardia), and E (Nausea and vomiting) are incorrect because they are not typical findings after administering naloxone. Somnolence would not be expected as naloxone counteracts sedation caused by opioids. Sudden onset of pain or discomfort is unrelated to naloxone administration. Hypertension and tachycardia are more indicative of opioid overdose, which naloxone would mitigate. Nausea and vomiting are also not common side effects of naloxone.