Nokea
The nurse explains perineal hygiene self-care postpartum to the client. She should be instructed to:
- A. Wear gloves for the procedure
- B. Place and adjust the pad from back to front
- C. Cleanse and wipe the perineum from front to back
- D. Protect the outer surface of the pad from contamination
Correct Answer: C
Rationale: (Tom) Perineal hygiene is a clean procedure and does not require the client to wear gloves. A care provider should wear gloves to adhere to universal precautions. The pad should be applied from front to back to prevent contamination of the birth canal or urinary tract from rectal bacteria. Wiping from front to back and discarding the wipe prevents contamination of the urinary tract and birth canal from rectal bacteria. The inner surface of the pad should not be touched to maintain asepsis.
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The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:
- A. Use a small hand-held hair dryer set on medium heat.
- B. Place a small heater near the child's bed.
- C. Turn the child at least every two hours.
- D. Allow one side to dry before changing positions.
Correct Answer: C
Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
- A. I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner.'
- B. You'll probably see strange things for a while until the PCP wears off.'
- C. Try to sleep. When you wake up, the devil will be gone.'
- D. You're probably feeling guilty because you used illegal drugs tonight.'
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.
The nurse is preparing a 6-year-old child for an IV insertion. Which one of the following statements by the nurse is appropriate when preparing a child for a potentially painful procedure?
- A. Some say this feels like a pinch or a bug bite. You tell me what it feels like.
- B. This is going to hurt a lot; close your eyes and hold my hand.
- C. This is a terrible procedure, so don't look.
- D. This will hurt only a little; try to be a big boy.
Correct Answer: A
Rationale: Educating the child about the pain may lessen anxiety. The child should be prepared for a potentially painful procedure but avoid suggesting pain. The nurse should allow the child his own sensory perception and evaluation of the procedure. The nurse should avoid absolute descriptive statements and allow the child his own perception of the procedure. The nurse should avoid evaluative statements or descriptions and give the child control in describing his reactions. False statements regarding a painful procedure will cause a loss of trust between the child and the nurse.
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
- A. Positive inotropic therapy
- B. Negative chronotropic therapy
- C. Increase in balance of myocardial O2 supply and demand
- D. Afterload reduction therapy
Correct Answer: A
Rationale: Inotropic therapy will increase contractility, which will increase myocardial O2 demand. Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.
A client is experiencing muscle weakness and lethargy. His serum K+ is 3.2. What other symptoms might he exhibit?
- A. Tetany
- B. Dysrhythmias
- C. Numbness of extremities
- D. Headache
Correct Answer: B
Rationale: Low potassium (3.2) causes dysrhythmias due to its role in cardiac muscle activity. The other symptoms are not associated with hypokalemia.