Nokea
On initial examination of a 15 month-old child with suspected otitis media, which group of findings would the registered nurse (RN) anticipate?
- A. Periorbital edema, absent light reflex and translucent tympanic membrane
- B. Irritability, rhinorrhea, and bulging tympanic membrane
- C. Diarrhea, fever, and reddened tympanic membrane
- D. Vomiting, pulling at ears and pearly white tympanic membrane
Correct Answer: B
Rationale: Irritability, rhinorrhea, and bulging tympanic membrane. These findings are characteristic of otitis media, indicating infection and inflammation of the middle ear.
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A client asks, 'What should I do to prepare for a colonoscopy?' Which instructions should the nurse reinforce to correctly answer the client’s question? Select all that apply.
- A. No food or drink is allowed 8 hours prior to the test
- B. Prophylactic antibiotics are taken as prescribed
- C. Smoking must be avoided after midnight
- D. The day prior to the procedure your diet will be clear liquids
- E. You will drink polyethylene glycol as directed the day before
Correct Answer: A,D,E
Rationale: Fasting 8 hours, clear liquids the day before, and polyethylene glycol are standard colonoscopy preparations. Antibiotics are not routine, and smoking cessation is not specific to the procedure.
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, 'I will receive tissue from
- A. a tissue bank.
- B. a pig.
- C. my thigh.
- D. synthetic skin.
Correct Answer: C
Rationale: Autografts are done with tissue transplanted from the client's own skin.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.
The nurse is preparing to suction a client who has a tracheostomy tube. Which of the following actions should the nurse take? Select all that apply.
- A. Administer 100% oxygen prior to suctioning the client
- B. Limit suctioning to 20 seconds during each suction pass
- C. Use sterile gloves and technique throughout the procedure
- D. Instill sterile normal saline into the tracheostomy tube prior to suctioning
- E. Apply suction while withdrawing the catheter from the tracheostomy tube
Correct Answer: A,C,E
Rationale: Pre-oxygenation, sterile technique, and suction on withdrawal prevent hypoxia and infection. Suctioning should be limited to 10-15 seconds, and saline instillation is not routinely recommended.
The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?
- A. A case worker from CPS will be visiting you in a few days. The case worker can explain it to you then
- B. Did you ask the HCP why it is being reported?
- C. Reporting your child’s injuries is required by law. It is for your child’s safety and protection
- D. Your explanation of your child’s injuries does not seem plausible
Correct Answer: C
Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.