Nokea
The licensed practical nurse is assisting the charge nurse in planning care for a client with a detached retina. Which of the following nursing diagnoses should receive priority?
- A. Alteration in comfort
- B. Alteration in mobility
- C. Alteration in skin integrity
- D. Alteration in O2 perfusion
Correct Answer: B
Rationale: Alteration in mobility is priority for a detached retina, as positioning and activity restrictions prevent further detachment. Comfort, skin integrity, and O2 perfusion are secondary concerns.
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The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication?
- A. Constipation
- B. Difficulty sleeping
- C. Discoloration of urine
- D. Dry mouth
Correct Answer: C
Rationale: Phenazopyridine causes orange-red urine discoloration, a benign effect. Constipation , insomnia , and dry mouth are not typical.
A client scheduled for a femoral popliteal bypass is to be assigned to a semi-private room. Which client would be the most suitable roommate for the client with a femoral popliteal bypass graft?
- A. A client with a pituitary tumor
- B. A client with respiratory sarcoidosis
- C. A client with a diabetic ulcer
- D. A client with a closed fracture of femur
Correct Answer: A
Rationale: The client with a pituitary tumor is the most suitable roommate as they are unlikely to have an infectious condition or mobility issues that could complicate recovery. Respiratory sarcoidosis may involve respiratory issues, increasing infection risk. A diabetic ulcer poses an infection risk due to potential open wounds. A closed femur fracture may involve similar mobility restrictions, complicating room logistics.
A client receives an injection of botulinum toxin type A for facial and neck rejuvenation. The nurse should monitor for which complication of this procedure?
- A. Abdominal rigidity and diarrhea
- B. Back pain and urge incontinence
- C. Difficulty swallowing and breathing
- D. Difficulty walking and hand tremor
Correct Answer: C
Rationale: Botulinum toxin can cause muscle weakness, leading to dysphagia and respiratory issues . Abdominal , urinary , or motor symptoms are not typical.
A nurse is teaching the parent of a nine month-old infant about diaper dermatitis. Which of the following measures would be appropriate for the nurse to include?
- A. Use only cloth diapers that are rinsed in bleach
- B. Do not use occlusive ointments on the rash
- C. Use commercial baby wipes with each diaper change
- D. Discontinue a new food that was added to the infant's diet just prior to the rash
Correct Answer: D
Rationale: Discontinue a new food that was added to the infant's diet just prior to the rash. New foods can be a cause of diaper dermatitis.
A client who is pregnant at 30 weeks gestation comes to the prenatal clinic. Which of the following vaccines may be administered safely at this prenatal visit? Select all that apply
- A. Influenza injection
- B. Influenza nasal spray
- C. Measles, mumps, and rubella
- D. Tetanus, diphtheria, and pertussis
- E. Varicella
Correct Answer: A,D
Rationale: Influenza injection and Tdap are safe and recommended in pregnancy. Nasal spray , MMR , and varicella are live vaccines, contraindicated in pregnancy.