Nokea
The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?
- A. Arterial septal defect
- B. Patent ductus arteriosus
- C. Aortic stenosis
- D. Ventricular septal defect
Correct Answer: D
Rationale: Ventricular septal defect. Surgical repair involves manipulation of the ventricular septum, increasing the risk of conduction disturbances.
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The nurse is participating in a staff presentation to review risk factors for skin cancer. Which of the following risk factors should the nurse include? Select all that apply.
- A. Family history of skin cancer
- B. High number of moles
- C. History of severe adolescent acne
- D. Immunosuppressant medication use
- E. Outdoor occupation
Correct Answer: A,B,D,E
Rationale: Risk factors for skin cancer include family history , high number of moles , immunosuppressant use increasing susceptibility, and outdoor occupation due to UV exposure. Severe acne is not a direct risk factor unless associated with specific treatments like radiation.
The client has contact dermatitis from poison ivy. Which statement, if made by the client, indicates that he understands how to care for his condition?
- A. A hot bath should make the itching go away.'
- B. I will use a good strong soap when I wash the affected areas.'
- C. A cool wet cloth to the area should help.'
- D. Wearing wool socks will help my itchy feet.'
Correct Answer: C
Rationale: A cool wet cloth soothes itching and inflammation in contact dermatitis. Hot baths, strong soaps, or wool exacerbate irritation.
The nurse is observing a staff member caring for a client who has varicella with active lesions. The nurse should intervene if the staff member is observed
- A. removing the protective gown with the contaminated side facing away from the body
- B. placing a surgical mask on the client before transport outside of the client's room
- C. removing the N95 respirator mask while inside the client's room
- D. keeping the door to the client's room closed at all times
Correct Answer: C
Rationale: Removing an N95 mask inside the room of a varicella client risks airborne exposure, requiring intervention. Other actions (A, B, D) follow correct infection control protocols.
A nurse from the float pool is giving medications on a pediatric unit and is to give medications to a 2-year-old child in room 534, bed B. The child in that room does not have an identification band. What is the best action for the nurse to take?
- A. Ask the child what his name is
- B. Give the medication to the child in room 534, bed B
- C. Refuse to give the medication
- D. Ask the adults beside the bed the name of the child in that bed
Correct Answer: C
Rationale: Refusing to give medication without proper identification ensures safety, as a 2-year-old cannot reliably confirm identity.
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
- A. 1 year of age
- B. 2 years of age
- C. 3 years of age
- D. 4 years of age
Correct Answer: B
Rationale: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.