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The family of a frail elderly man who is bedridden asks the nurse what they can do to prevent bedsores. Which response by the nurse is best?
- A. Get him out of bed at least once a day.'
- B. Turn him every two hours.'
- C. Rub his buttocks and apply lotion several times a day.'
- D. Change the sheets every day.'
Correct Answer: B
Rationale: Turning every two hours relieves pressure on bony prominences, preventing pressure ulcers. Getting out of bed may be infeasible, and rubbing or sheet changes are less effective.
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The nurse is reviewing teaching with the parents of a child who has tinea capitis (ringworm of the scalp) and is newly prescribed griseofulvin oral suspension and 1% selenium sulfide shampoo. Which statement by the child's parent requires the nurse to intervene?
- A. I will discontinue the griseofulvin once the ringworm stops itching and the scales go away.
- B. I will give the griseofulvin suspension to my child after consumption of high-fat food, like ice cream.
- C. I will monitor my child for increased sensitivity to sunlight while taking griseofulvin.
- D. I will wash my child's scalp a few times per week with the medicated shampoo.
Correct Answer: A
Rationale: Griseofulvin requires a full course (6-8 weeks) to eradicate tinea capitis, even if symptoms resolve, to prevent recurrence. High-fat foods enhance absorption, photosensitivity is a side effect, and shampoo use a few times weekly is appropriate.
The nurse is planning to give a 3 year-old child oral digoxin. Which of the following is the best approach by the nurse?
- A. Do you want to take this pretty red medicine?
- B. You will feel better if you take your medicine.
- C. This is your medicine, and you must take it all right now.
- D. Would you like to take your medicine from a spoon or a cup?
Correct Answer: D
Rationale: Would you like to take your medicine from a spoon or a cup? Offering a choice empowers the child and reduces resistance.
The nurse is caring for a client with Cushing's syndrome. The nurse should carefully assess the client for signs of:
- A. Hypoglycemia
- B. Infection
- C. Hypovolemia
- D. Hyperinsulinemia
Correct Answer: B
Rationale: Cushing's syndrome causes immunosuppression, increasing infection risk . Hypoglycemia , hypovolemia , and hyperinsulinemia are not primary concerns.
The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?
- A. The cholesterol level is slightly high, but exercise and a low-fat diet should reduce it to normal.
- B. The cholesterol level is below normal levels, but this is good.
- C. The cholesterol level is high. The neighbor should talk with the physician about ways to lower it.
- D. The cholesterol is within normal limits.
Correct Answer: C
Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.
The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?
- A. Assist client, post hip fracture repair, to the bathroom
- B. Check the appearance of client's wound
- C. Discontinue nasogastric tube if client tolerates oral liquids
- D. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
Correct Answer: A
Rationale: Assisting with mobility, such as to the bathroom, is within the nursing assistant's scope. Wound assessment, tube discontinuation, and treating hypoglycemia require nursing judgment and are outside their scope.