Nokea
The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.
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A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client
- A. Has increased airway obstruction
- B. Has improved airway obstruction
- C. Needs to be suctioned
- D. Exhibits hyperventilation
Correct Answer: A
Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway. Therefore, the obstruction has increased or worsened.
A 23-year-old man comes to the AIDS clinic for treatment of large, painful, purplish-brown open areas on his right arm and back.
The nurse should instruct the client to
- A. clean the area carefully with soap and warm water every day and cover them with a sterile dressing.
- B. soak in a warm tub twice a day and rub the areas with a washcloth before covering them.
- C. shower daily using a mild antimicrobial soap from a pump dispenser and leave the lesions uncovered.
- D. clean the lesions twice a day with a diluted solution of povidone-iodine (Betadine) and leave them open to the air.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-open Kaposi's sarcoma lesions should be cleaned and dressed daily to prevent secondary infection (2) not done because of risk of secondary skin infection (3) important to keep the skin clean to prevent secondary skin infection but should be covered due to open areas (4) treatment for herpes simplex virus abscess, not Kaposi's sarcoma
An adult who is on an American Dietetic Association (ADA) diabetic diet tells the nurse that she will not eat the asparagus that is on her tray. What would be an appropriate substitute for the nurse to offer?
- A. Broccoli
- B. Corn
- C. Peas
- D. Beets
Correct Answer: A
Rationale: Broccoli, like asparagus, is a non-starchy vegetable, fitting the ADA diabetic diet's emphasis on low-glycemic foods. Corn, peas, and beets are higher in carbohydrates.
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse's first action should be:
- A. Place her in Trendelenburg position.
- B. Slow the IV infusion.
- C. Administer oxygen per nasal cannula.
- D. Speed the IV infusion of normal saline.
Correct Answer: D
Rationale: Hypotension from epidural anesthesia is treated by increasing IV fluid volume with normal saline to restore blood pressure, so D is correct. Trendelenburg is not recommended, slowing the IV would worsen hypotension, and oxygen is secondary.
An infant is suspected of having coarctation of the aorta. Which assessment finding is most related to coarctation of the aorta?
- A. Respirations are 70 per minute.
- B. Blood pressure is higher in the upper extremities than in the lower extremities.
- C. There is a heart murmur.
- D. Heart rate is 150 beats per minute.
Correct Answer: B
Rationale: Coarctation of the aorta causes aortic narrowing, leading to higher blood pressure in the upper extremities compared to the lower, a hallmark sign.