Nokea
The nurse is assessing a client who had a colon resection two days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. Which action should the nurse take?
- A. Immediately place the client in the prone position.
- B. Apply a sterile, saline-moistened dressing to the wound.
- C. Administer atropine to decrease abdominal secretions.
- D. Wrap the abdomen with an ACE bandage.
Correct Answer: B
Rationale: Applying a sterile, saline-moistened dressing protects the dehisced wound and prevents infection. Prone positioning (A) is inappropriate, atropine (C) doesn’t address dehiscence, and an ACE bandage (D) may worsen the condition.
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Which of the following characterizes peer group relationships in eight- and nine-year-olds?
- A. Activities are usually cooperative and focused on a single best friend
- B. Activities are usually competitive with loosely organized groups
- C. Children usually play in groups with members of the same sex
- D. Children usually play in groups of three with mixed sexes
Correct Answer: C
Rationale: Eight- and nine-year-olds typically form same-sex peer groups, engaging in activities that foster social skills and group identity.
A client in labor admits to using alcohol throughout the pregnancy. The most recent use was the day before. Based on the client's history, the nurse should give priority to assessing the newborn for:
- A. Respiratory depression
- B. Wide-set eyes
- C. Jitteriness
- D. Low-set ears
Correct Answer: C
Rationale: Fetal alcohol exposure, especially recent use, can cause neonatal withdrawal symptoms like jitteriness. Respiratory depression is less common, and physical anomalies like wide-set eyes or low-set ears are associated with chronic exposure.
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glasgow coma scale.
Correct Answer: A
Rationale: Normal ICP is 5-15 mmHg. A reading of 17 mmHg is elevated, indicating potential brain swelling, and requires immediate notification of the physician. The Glasgow scale complements but does not replace ICP monitoring.
A female client was recently diagnosed with gastric cancer. She entered the hospital and had a total gastrectomy with esophagojejunostomy. Her postoperative recovery was uneventful. On conducting discharge teaching, the nurse discusses changes in bodily function and lifestyle changes with the client. In order to prevent pernicious anemia, the nurse stresses that the client must:
- A. Receive monthly blood transfusions
- B. Increase the amount of iron in her diet
- C. Eat small quantities several times daily until she is able to tolerate food in moderate portions
- D. Understand the need for Vitamin B12 replacement therapy
Correct Answer: D
Rationale: Monthly blood transfusions are not indicated postgastrectomy. Increasing iron in the client's diet may cause irritation and will not alleviate pernicious anemia. It may be necessary that the client eat small meals several times per day, but this measure has no relevance to prevention of pernicious anemia. Pernicious anemia is caused by lack of Vitamin B12, and replacement therapy will be necessary because the client's stomach has been removed.
A nurse indicates that she is licensed in her new state of residence even though reciprocity has not been granted. The nurse’s action can result in a charge of:
- A. Fraud
- B. Tort
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Claiming licensure without reciprocity is a deliberate misrepresentation, constituting fraud. A tort is a civil wrong, malpractice involves substandard care, and negligence implies carelessness, none of which fully describe this intentional act.