Nokea
The nurse in the pediatric clinic is planning to reinforce postoperative teaching to parents. The nurse should talk with the parent of which child first?
- A. 2-year-old with bilateral tympanostomy tubes who has a small piece of plastic in the right outer ear
- B. 4-year-old post adenotonsillectomy who is now reporting ear pain
- C. 6-year-old with strep throat who needs a note to return to school 24 hours after starting antibiotics
- D. 7-year-old 5 days post tonsillectomy who wants to return to soccer practice tomorrow
Correct Answer: A
Rationale: A foreign object in the ear (A) poses an immediate risk of injury or infection, requiring urgent attention. Ear pain post-adenotonsillectomy (B) is common and less urgent. School clearance (C) and returning to sports (D) are non-emergent.
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The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?
- A. I will need to lie on my stomach during the procedure.
- B. I should go to the bathroom to urinate before the procedure.
- C. I understand that a needle will be inserted between the bones in my lower spine during the procedure.
- D. I may experience a sharp pain radiating down my leg during the procedure, but it should pass quickly.
Correct Answer: A
Rationale: Lumbar punctures are typically performed in a lateral or sitting position, not prone (A), requiring clarification. Urinating beforehand (B), needle insertion (C), and transient pain (D) are correct.
A client with coronary artery disease was discharged home with a prescription for sublingual nitroglycerin to treat angina. Which statement by the client indicates that further teaching is required?
- A. I may experience flushing but will continue to take the medication as prescribed.
- B. I should lie down before taking the medication.
- C. I should not swallow the tablet.
- D. I will wait to call 911 if I don't experience relief after the third tablet.
Correct Answer: D
Rationale: Delaying 911 after three doses (D) is dangerous; clients should call after no relief from the first dose or after three doses (5 minutes apart). Flushing (A), lying down (B), and not swallowing (C) are correct.
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
- A. Right ventricle, left ventricle, right atrium, left atrium
- B. Left ventricle, right ventricle, left atrium, right atrium
- C. Right atrium, right ventricle, left atrium, left ventricle
- D. Right atrium, left atrium, right ventricle, left ventricle
Correct Answer: C
Rationale: Right atrium, right ventricle, left atrium, left ventricle. This is the correct pathway of blood flow through the heart.
The nurse is caring for a client who is receiving peritoneal dialysis and is reporting chills and abdominal discomfort. The nurse notes rebound tenderness with palpation. Which of the following actions would be a priority for the nurse to take?
- A. Discontinue the exchange and collect a peritoneal fluid specimen for culture and sensitivity.
- B. Warm the remaining dialysate fluid and increase the dwell time of the exchange.
- C. Administer a dose of oxycodone prescribed PRN for the client.
- D. Place the client in the high-Fowler position in bed.
Correct Answer: A
Rationale: Chills, discomfort, and rebound tenderness suggest peritonitis, requiring fluid culture (A). Warming dialysate (B), pain medication (C), and positioning (D) do not address the infection.
The nurse supporting a family who has just experienced a sudden and unexpected death needs to know:
- A. that survivors have greater emotional turmoil and shock than when death is expected.
- B. that survivors have less emotional turmoil and shock than when death is expected.
- C. that survivors have the same emotional turmoil and shock as when death is expected.
- D. that survivors have little emotional turmoil and shock because they were not there.
Correct Answer: A
Rationale: Sudden death produces greater emotional turmoil and shock in survivors than does a gradual, expected death.