Nokea
The client with hyperemesis gravidarum is at risk for developing:
- A. Respiratory alkalosis without dehydration
- B. Metabolic acidosis with dehydration
- C. Respiratory acidosis without dehydration
- D. Metabolic alkalosis with dehydration
Correct Answer: B
Rationale: Hyperemesis gravidarum causes prolonged vomiting leading to dehydration and loss of stomach acid resulting in metabolic acidosis. The dehydration exacerbates the acid-base imbalance.
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The nurse is caring for a client with a history of Crohn’s disease. Which dietary recommendation is most appropriate?
- A. High-fiber diet
- B. Low-residue diet
- C. High-fat diet
- D. Low-protein diet
Correct Answer: B
Rationale: A low-residue diet reduces bowel irritation in Crohn’s disease, minimizing symptoms like diarrhea. High-fiber diets exacerbate symptoms, and high-fat or low-protein diets are not indicated.
A camp nurse is applying sunscreen to a group of children enrolled in swim classes. Chemical sunscreens are most effective when applied:
- A. Just before sun exposure
- B. Five minutes before sun exposure
- C. 15 minutes before sun exposure
- D. 30 minutes before sun exposure
Correct Answer: D
Rationale: Chemical sunscreens require 30 minutes to absorb into the skin for optimal UV protection. Applying closer to exposure reduces effectiveness.
The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?
- A. Immediately place the client in the prone position.
- B. Apply a sterile, saline-moistened dressing to the wound.
- C. Administer atropine to decrease abdominal secretions.
- D. Wrap the abdomen with an ACE bandage.
Correct Answer: B
Rationale: Applying a sterile, saline-moistened dressing protects the dehisced wound and prevents infection. Prone positioning (A) is inappropriate, atropine (C) doesn’t address dehiscence, and an ACE bandage (D) may worsen the condition.
A 6-year-old girl is visiting the outpatient clinic because she has a fever and a rash. The doctor diagnoses chickenpox. Her mother asks the nurse how many baby aspirins her daughter can have for fever. The nurse should:
- A. Advise the mother not to give her aspirin
- B. Ask if the client is allergic to aspirin before giving further information
- C. Assess the function of the client's cranial nerve VIII
- D. Check the aspirin bottle label to determine milligrams per tablet
Correct Answer: A
Rationale: Aspirin taken during a viral infection has been implicated as a predisposing factor to Reye's syndrome in children and adolescents. Children and adolescents should not be given aspirin. Allergy to aspirin is not related to Reye's syndrome. Tinnitus, caused by damage to the acoustic nerve, occurs with aspirin toxicity, but this is not related to Reye's syndrome. A 6-year-old child should not be given any baby aspirin.
On an assessment of a client's mouth, the nurse notices white patches on the buccal mucosa. The nurse tries to obtain a sample for a culture, but the lesion cannot be rubbed off. The nurse would suspect that this lesion is:
- A. Xerostomia
- B. Candidiasis
- C. Leukoplakia
- D. Stomatitis
Correct Answer: C
Rationale: Leukoplakia cannot be rubbed off.