Nokea
The mother of a 7-month-old child born 6 weeks early asks the nurse what play activities and toys are appropriate for her child. Which of the following should the nurse suggest?
- A. Picture books
- B. Peek-a-boo
- C. Rattle
- D. Colored blocks
Correct Answer: B
Rationale: Peek-a-boo is an age-appropriate activity for a 7-month-old, promoting social and cognitive development. Picture books and colored blocks are better for older children, and a rattle may be less engaging for this age.
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A child with the diagnosis of Hirschsprung's disease has a temporary colostomy. The nurse provides instructions to the parents about colostomy care at home. Which statement by the parents indicates their understanding of the instructions?
- A. We will give antidiarrheal medications.
- B. We will report signs of skin breakdown.
- C. We will give saline water enemas if my child doesn't pass stool.
- D. We will apply a heat lamp to any moist red tissue around the stoma.
Correct Answer: B
Rationale: The parents are instructed to report signs of skin breakdown or stomal complications, such as ribbonlike stools or failure to pass flatus or stools, to the primary health care provider or the nurse. Moist, red granulation tissue may grow around an ostomy site and does not require special treatment. The remaining options are incorrect actions and considered contraindicated.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is prescribed budesonide (Pulmicort). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using budesonide prevents oral candidiasis, a common side effect of inhaled corticosteroids.
The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?
- A. Continuous bubbling in the water seal chamber.
- B. Tubing clamped near the insertion site.
- C. Chest tube secured to the chest wall.
- D. Suction set at 20 cm H2O.
Correct Answer: B
Rationale: Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.
A client has been prescribed transcutaneous electrical nerve stimulation (TENS) by the primary health care provider for the relief of chronic pain. Which statement by the client would indicate to the nurse a need for further teaching regarding this pain relief measure?
- A. I understand that this will help relieve the pain.
- B. This unit will eliminate the need for taking so many pain medications.
- C. I am not real happy that I have to stay in the hospital for this treatment.
- D. I am not sure that I am going to like those electrodes attached to my skin.
Correct Answer: C
Rationale: It is not necessary for the client to remain in the hospital for this treatment. The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes.
Identify this cardiac rhythm strip. Fill in the blank. A. Asystole B. Atrial flutter C. Supraventricular Tachycardia D. Premature Atrial Contractions
- B. Asystole
- C. Atrial flutter
- D. Supraventricular Tachycardia
- E. Premature Atrial Contractions
Correct Answer: A
Rationale: Asystole is a flatline rhythm indicating no electrical activity, assuming the strip matches this description.