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The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?
- A. Cross the arms and legs.
- B. Perform a log roll.
- C. Raise the hips.
- D. Flex the knees.
Correct Answer: B
Rationale: The log roll technique maintains spinal alignment, critical after surgical spinal instrumentation.
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The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. Which information should the nurse provide?
- A. Repair should be done before the child is potty-trained.
- B. The urethral repair should be done after sexual maturity.
- C. Surgery should be done by one month to prevent bladder infections.
- D. Delaying the repair until school age reduces castration fears.
Correct Answer: A
Rationale: Repair before potty-training (6-12 months) prevents urinary dysfunction and psychosocial issues.
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?
- A. Hemiplegia.
- B. Fever.
- C. Vigorous feeding and satiation.
- D. Hypotension and tachycardia.
Correct Answer: D
Rationale: Aortic stenosis can lead to heart failure and pulmonary edema, causing bilateral fine crackles, with hypotension and tachycardia as additional signs of decreased cardiac output.
The nurse is caring for an adolescent with type 1 diabetes mellitus presenting with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the nurse take first?
- A. Review prior insulin prescriptions.
- B. Obtain point-of-care glucose.
- C. Assess urine for ketones.
- D. Check blood pressure.
Correct Answer: B
Rationale: Obtaining a point-of-care glucose reading is the first step to assess current blood glucose levels, given symptoms suggestive of hyperglycemia.
During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?
- A. Encourage the client to discuss her need for contraceptives with her parents.
- B. Counsel the client about the risks and benefits of using oral contraceptives.
- C. Explain that she needs parental approval to receive contraceptives.
- D. Tell the client how to receive a variety of free oral contraceptives from the clinic.
Correct Answer: B
Rationale: Providing counseling about the risks and benefits of oral contraceptives ensures the client is informed and respects her autonomy and privacy while ensuring she receives necessary information.
The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Avoid smoke exposure.
- B. Inspect the infant's ears daily.
- C. Position prone after feeding.
- D. Breastfeed frequently.
Correct Answer: A
Rationale: Avoiding smoke exposure reduces the risk of otitis media recurrence, a known risk factor.