Nokea
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.
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The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 3 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
The nurse updates the nursing note with an environmental assessment for a 67-year-old female client with progressive multiple sclerosis. The nurse should first address the client's
- A. fatigue.
- B. sensation in the extremities.
- C. nutritional intake.
- D. environmental hazards.
Correct Answer: D
Rationale: Environmental hazards (e.g., furniture used for ambulation) pose an immediate fall risk, which is critical to address first for safety.
The nurse provides discharge teaching to a client prescribed a cane for left-sided weakness. Which instruction should the nurse provide?
- A. Advance the cane along with your stronger leg.
- B. Remove the rubber tip when going upstairs.
- C. Measure the height of the cane to your elbow.
- D. Secure the cane in your right hand.
Correct Answer: D
Rationale: The cane is held in the right hand (stronger side) for left-sided weakness to support the weaker leg. The stronger leg moves first, rubber tips stay on, and height is measured to the greater trochanter.
The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client
- A. Trendelenburg's position.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Right lateral with the head of the bed lowered.
Correct Answer: C
Rationale: The left lateral position allows the enema solution to flow into the sigmoid colon via gravity. Other positions are less effective or impractical.
The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?
- A. Spills sterile water onto the sterile field
- B. Uses sterile gloves to handle sterile supplies on a sterile field
- C. Has sterile gauze placed into the sterile field
- D. Keeps the sterile field above their waist
Correct Answer: A
Rationale: Spilling sterile water contaminates the sterile field, requiring follow-up. Other actions are consistent with aseptic technique.