Nokea
The homecare nurse is visiting an infant who had a myelomeningocele repair.
The homecare nurse determines that the parents are accepting of their infant if which of the following is observed?
- A. The parents state that the infant will outgrow this problem in time.
- B. The parents ask a neighbor to perform bladder expression.
- C. The parents measure the head circumference daily.
- D. The parents relate that they believe the child will walk in one year.
Correct Answer: C
Rationale: Strategy: Think about each statement and how it relates to myelomeningocele. (1) child has a chronic problem (2) indicates the parents' lack of interest and inability to care for the child (3) correct-parents' participation in care may be first sign of acceptance; head circumference measurement is important due to risk of hydrocephalus following surgery; even simple care like bathing child could bring acceptance (4) shows a lack of understanding about myelomeningocele
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After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain.
The nurse is caring for a client receiving treatment for hypoparathyroidism. The nurse determines that treatment has been successful if which of the following was observed?
- A. The client's output is 1500 cc of clear straw-colored urine.
- B. The client is unable to state his name.
- C. The client denies numbness and tingling.
- D. The client loses 3 pounds in one week.
Correct Answer: C
Rationale: Hypoparathyroidism causes hypocalcemia, leading to numbness and tingling. Their absence indicates successful calcium therapy. Options A, B, and D are unrelated or indicate other issues.
An abdominal wound irrigation with a normal saline solution is ordered for a client. To perform this procedure, the nurse should
- A. warm the irrigating solution to 110°F (43.3°C).
- B. establish a sterile field that includes the irrigating equipment.
- C. direct the irrigating solution at the outer edges of the wound, then the center of the wound.
- D. aspirate the irrigating fluid with a syringe to prevent accumulation in the wound.
Correct Answer: B
Rationale: requires strict aseptic technique
While scheduling the administration of bromocriptine (Parlodel), which nursing action has the HIGHEST priority?
- A. The medication should be taken once a day for six weeks.
- B. The medication should be taken with orange juice.
- C. The medication should be taken in the morning and at bedtime.
- D. The medication should be taken with meals.
Correct Answer: D
Rationale: will decrease GI upset
A client is admitted to the unit with pregnancy-induced hypertension (PIH).
Which of the following actions is the priority nursing action?
- A. Start an IV.
- B. Obtain the vital signs.
- C. Administer magnesium sulfate.
- D. Notify the lab to draw blood.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) implementation, not a priority action (2) correct-assessment, important to do a baseline assessment in order to successfully evaluate the treatment (3) implementation, not a priority action (4) implementation, not a priority action