Nokea
The nurse is caring for a 10-year-old child who has classic hemophilia. He is admitted with a swollen right knee that is very painful. The nurse should plan to include which of the following as a priority in the care of this child upon admission?
- A. Range-of-motion exercises to maintain joint mobility
- B. Ambulation at least three times a day to prevent immobility complications
- C. A bed cradle to reduce pain
- D. Offer 250 mL of fluid every hour to prevent hemarthrosis
Correct Answer: C
Rationale: A bed cradle keeps bedding off the painful, swollen knee (hemarthrosis), reducing discomfort, a priority in acute hemophilia management.
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A nurse is providing care for an elderly patient with dementia. Which of the following interventions is most appropriate?
- A. Encourage the patient to make complex decisions
- B. Provide a structured routine
- C. Limit social interactions
- D. Avoid physical activity
Correct Answer: B
Rationale: A structured routine reduces confusion and promotes safety in dementia. Complex decisions overwhelm, social interactions benefit, and activity supports health.
A nurse is teaching a patient about the use of albuterol (Proventil) for asthma. Which of the following instructions should be included?
- A. Use this medication daily to prevent asthma attacks.
- B. Use this medication only when you feel short of breath.
- C. Use this medication at bedtime.
- D. Use this medication before exercise.
Correct Answer: D
Rationale: Albuterol, a rescue inhaler, is used before exercise to prevent exercise-induced bronchospasm. It’s not for daily prevention, symptom-only use, or bedtime dosing.
Following the death of a client, a nursing assistant begins to cry uncontrollably and is unable to provide care for the other assigned clients. The nurse should:
- A. Send the nursing assistant home for the remainder of the day.
- B. Explain to the nursing assistant that she will have to learn to cope with loss.
- C. Send the nursing assistant to the lounge and care for the clients herself.
- D. Encourage the nursing assistant to express her feelings about dying.
Correct Answer: D
Rationale: Encouraging the nursing assistant to express feelings supports emotional processing and professional growth. Sending her home or to the lounge avoids the issue. Coping lectures are dismissive.
Steam inhalation is prescribed for a client. Which of the following safety precautions should the nurse include in the client's instructions?
- A. Use distilled water in the humidifier.
- B. Keep the humidifier filled to the top with water.
- C. Turn the humidifier off when not in use.
- D. Clean the humidifier every 2 weeks.
Correct Answer: C
Rationale: Turning off the humidifier when not in use prevents electrical hazards and bacterial growth. Distilled water is ideal but not critical, overfilling is unnecessary, and cleaning frequency depends on use.
A nurse is caring for a patient with diabetes mellitus who is scheduled for surgery. Which of the following is the most important preoperative assessment?
- A. Blood glucose level.
- B. Electrolyte levels.
- C. Complete blood count (CBC).
- D. Urinalysis.
Correct Answer: A
Rationale: Blood glucose control is critical preoperatively in diabetes to prevent complications like wound infections or ketoacidosis. Electrolytes, CBC, and urinalysis are important but secondary, as glucose directly impacts surgical outcomes.