Nokea
The nurse is caring for a 7-year-old child with constipation. The child's mother asks the nurse what she can do to help prevent another episode. What information would the nurse include in her response?
- A. Give enemas until the child runs clear.
- B. Give laxatives daily on a regular basis.
- C. Provide lots of milk and sugary foods to promote defecation.
- D. Have the child sit on the toilet for 5 to 10 minutes about 20 to 30 minutes after meals to encourage defecation.
Correct Answer: D
Rationale: Encouraging regular toilet habits after meals promotes bowel regularity without relying on invasive or inappropriate measures like enemas or excessive milk.
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The nurse is preparing a client with gastroesophageal reflux disease (GERD) for discharge. The nurse should tell the client to:
- A. Eat a small snack before bedtime
- B. Sleep on his right side
- C. Avoid carbonated beverages
- D. Increase his intake of citrus fruits
Correct Answer: C
Rationale: Carbonated beverages can increase stomach pressure and worsen GERD symptoms by promoting acid reflux.
A client is being treated for cancer with linear acceleration radiation. The physician has marked the radiation site with a blue marking pen. The nurse should:
- A. Remove the unsightly markings with acetone or alcohol
- B. Cover the radiation site with loose gauze dressing
- C. Sprinkle baby powder over the radiated area
- D. Refrain from using soap or lotion on the marked area
Correct Answer: D
Rationale: Soap or lotion can remove radiation site markings or irritate the skin, so they should be avoided to ensure accurate treatment.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish his supply every 3 months
- B. Take one every 15 minutes if pain occurs
- C. Leave the medication in the brown bottle
- D. Crush the medication and take with water
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency.
The nurse is observing a student nurse administering ear drops to a 2-year-old. Which observation by the nurse would indicate correct technique?
- A. Holds the child's head up and extended
- B. Places the head in chin-tuck position
- C. Pulls the pinna down and back
- D. Irrigates the ear before administering medication
Correct Answer: C
Rationale: For children under 3, pulling the pinna down and back straightens the ear canal for proper ear drop administration.
A client with cancer is admitted to the oncology unit. Stat lab values reveal Hgb 12.6, WBC 6500, K+ 1.9, uric acid 7.0, Na+ 136, and platelets 178,000. The nurse evaluates that the client is experiencing which of the following?
- A. Hypernatremia
- B. Hypokalemia
- C. Myelosuppression
- D. Leukocytosis
Correct Answer: B
Rationale: A potassium level of 1.9 mEq/L indicates hypokalemia, which is a critical electrolyte imbalance.