Nokea
The mother of a 2-year-old who has been bitten by the family dog asks the nurse what to do about the bite. What should the nurse tell the mother?
- A. You need to take the child to the local urgent recommended by the 1980'
- B. Wash the bite area with lots of running water, and then check the injury.'
- C. Determine when the child's latest tetanus vaccine was administered.'
- D. Make an appointment to see the child's physician now to start rabies shots.'
Correct Answer: B
Rationale: Washing the bite area with running water helps clean the wound and reduce infection risk. Tetanus status and rabies risk can be assessed afterward, but immediate cleaning is the priority.
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A client with a diagnosis of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following side effects?
- A. Infection.
- B. Hypotension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Etanercept, a TNF inhibitor, increases the risk of infections due to immune suppression.
The nurse is assessing a client with suspected appendicitis. Which finding supports this diagnosis?
- A. Pain relief with knee flexion.
- B. Rebound tenderness in the right lower quadrant.
- C. Increased bowel sounds.
- D. Absence of fever.
Correct Answer: B
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis due to peritoneal irritation.
The nurse is auscultating the lung sounds of a client with long-standing emphysema. The nurse should determine if the client has?
- A. Fine crackles
- B. Diminished breath sounds
- C. Stridor
- D. Pleural friction rub
Correct Answer: B
Rationale: Diminished breath sounds are typical in emphysema due to air trapping and reduced airflow. Crackles, stridor, and pleural friction rubs are associated with other conditions.
A client with a diagnosis of multiple sclerosis is prescribed baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Baclofen, a muscle relaxant, commonly causes drowsiness, which the nurse should monitor in clients with multiple sclerosis.
A 38-year-old client with a history of type 1 diabetes mellitus is admitted with an infected foot ulcer. The nurse should recognize that wound healing may be delayed because of:
- A. Increased tissue perfusion.
- B. Impaired collagen synthesis.
- C. Enhanced immune response.
- D. Increased fibroblast activity.
Correct Answer: B
Rationale: In diabetes, impaired collagen synthesis due to poor glycemic control delays wound healing, increasing infection risk.