Nokea
If the client asks the nurse for instructions on safe condom use, which information needs to be stressed?
- A. Condoms should be stored in a warm, dry place to prevent damage.
- B. Condoms are generally lubricated with mineral oil or petroleum jelly.
- C. A condom should be applied before the penis becomes erect.
- D. During application, a ½†space should be left at the end of the condom.
Correct Answer: D
Rationale: Leaving a ½†space at the condom's tip prevents breakage by allowing room for semen, a critical aspect of safe condom use to ensure effectiveness.
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Which activity is most appropriate for the child with juvenile rheumatoid arthritis?
- A. Skipping rope
- B. Softball
- C. Swimming
- D. Running
Correct Answer: C
Rationale: Swimming is a low-impact activity that promotes joint mobility and muscle strength without stressing inflamed joints, making it ideal for a child with JRA.
Which intervention is best to prevent complications associated with traction and immobility?
- A. Offer the child fluids on a frequent basis.
- B. Assist the child to select low-fiber foods.
- C. Assist the child to select low-fiber foods daily.
- D. Reposition the child onto the side every 2 hours.
Correct Answer: A
Rationale: Frequent fluid intake prevents urinary stasis and constipation, common complications of immobility in traction, supporting hydration and kidney function.
The nurse would be correct to set the infusion pump for which hourly rate?
- A. 50 mL
- B. 75 mL
- C. 100 mL
- D. 125 mL
Correct Answer: D
Rationale: The order is 1,000 mL over 8 hours. Dividing 1,000 by 8 gives 125 mL/hour, the correct rate for the infusion pump.
The client with oligohydramnios and possible intrauterine growth restriction gives birth. The newborn’s 1-minute Apgar score was 6,and the 5-minute Apgar score is 7. Which conclusion should the nurse make from this information?
- A. A low Apgar score at 1 minute correlates with infant mortality.
- B. The 5-minute Apgar score of 7 is within normal parameters.
- C. Neurological problems are unlikely with a 5-minute score of 7.
- D. Oligohydramnios would not have affected the Apgar score.
Correct Answer: B
Rationale: A 5-minute Apgar score at or above 7 is considered normal. A low 1-minute score is not associated with mortality but a low 5-minute score is. Apgar scores are poor predictors of neurological outcomes and oligohydramnios can affect scores.
Which finding by the nurse strongly indicates that a child is experiencing hypokalemia?
- A. Full, bounding pulses
- B. Muscle weakness
- C. Elevated blood pressure
- D. Hyperactive bowel sounds
Correct Answer: B
Rationale: Hypokalemia causes muscle weakness due to impaired muscle contraction, a key manifestation resulting from low potassium levels affecting neuromuscular function.