Nokea
The client is admitted for a bronchoscopy this morning. Which question is essential for the nurse to ask the client?
- A. When did you last eat?'
- B. Did you take the laxative as ordered?'
- C. What has the doctor told you about your procedure?'
- D. Have you had conscious sedation before?'
Correct Answer: A
Rationale: Bronchoscopy requires NPO status to prevent aspiration; confirming last intake is essential. Laxatives, procedure knowledge, or sedation history are secondary.
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The nurse is talking with a group of parents about puberty. The nurse should include that the first sign of puberty in clients of the male sex is
- A. increased height
- B. greater muscle mass
- C. testicular enlargement
- D. increased length of the penis
Correct Answer: C
Rationale: Testicular enlargement (C) is the first sign of puberty in males, occurring before height increase (A), muscle mass gain (B), or penile growth (D).
The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?
- A. Applesauce, green beans, bread, and butter
- B. Peanut butter and jelly sandwich, carrots, and milk
- C. Broccoli, spinach salad with tomatoes, and orange juice
- D. Macaroni and cheese, pickles, and hot chocolate
Correct Answer: C
Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.
Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.
- A. Avoid the arm on the affected side after a mastectomy
- B. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
- C. If necessary to use an arm with IV infusing, draw proximal to infusion point
- D. Insert the needle bevel up at a 15-degree angle to the skin
- E. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answer: A,B,C
Rationale: Avoiding the mastectomy side (A), limiting attempts to two (B), and drawing proximal to an IV (C) are correct. A 15-degree angle (D) is for IVs, not phlebotomy, and capillary samples avoid the finger pad center (E).
The nurse is teaching a group of parents about gross motor development of a 2-year old. According to the Denver Developmental Screening Test, which behavior is an example of the normal gross motor skill of a 2-year old?
- A. She can pull a toy behind her.
- B. She can copy a horizontal line.
- C. She can build a tower of eight blocks.
- D. She can broad jump.
Correct Answer: A
Rationale: Pulling a toy is a gross motor skill for a 2-year-old per the Denver Test. Copying a line and building a tower of eight blocks are fine motor skills. Broad jumping develops later.
The nurse is preparing an injection of IM haloperidol from a glass ampule. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Attaches an 18-gauge injection needle to a syringe for withdrawal of medication
- B. Breaks the ampule neck away from the nurse's body to prevent injury from the glass
- C. Disposes of the empty glass ampule in a sharps container
- D. Injects air into the glass ampule prior to withdrawing the medication
- E. Rests and steadies the needle on the ampule's outer rim to withdraw medication
Correct Answer: B,C
Rationale: Breaking the ampule away from the body (B) and disposing in a sharps container (C) are safe practices. An 18-gauge needle (A) is too large, injecting air (D) is unnecessary, and resting the needle on the rim (E) risks contamination.