Nokea
The nurse is caring for an infant admitted from the delivery room. Which finding should be reported?
- A. Acyanosis
- B. Acrocyanosis
- C. Halequin sign
- D. Absent femoral pulses
Correct Answer: D
Rationale: Absent femoral pulses suggest coarctation of the aorta, a critical condition.
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A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, 'I don't believe the doctor; I think he has me confused with another patient.' This is an example of which of Kubler-Ross' stages of dying?
- A. Denial
- B. Anger
- C. Depression
- D. Bargaining
Correct Answer: A
Rationale: The client's statement reflects denial, a stage where patients refuse to accept a terminal diagnosis, per Kubler-Ross' model.
If a client with psoriasis is to begin NB-UVB phototherapy, how long should the initial treatment be?
- A. 30 seconds to 1 minute
- B. 1 to 2 minutes
- C. 5 to 10 minutes
- D. 15 to 20 minutes
Correct Answer: A
Rationale: Initial NB-UVB phototherapy starts with 30 seconds to 1 minute (A) to assess skin tolerance and prevent burns. Longer durations (B, C, D) are used in subsequent sessions.
The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?
- A. a client in a halo vest following an automobile accident
- B. a child with severe autism who is having a tonsillectomy
- C. a teenager who broke her leg during cheerleader practice
- D. a schoolteacher who was hospitalized for shortness of breath
Correct Answer: B
Rationale: Severe autism often involves sensory processing issues, increasing risk for sensory perception alterations, especially during stressful procedures like surgery.
Which of the following statements regarding proper use of a cane is correct?
- A. When standing, the cane should reach a height even with the natural waist.
- B. When walking downstairs, the cane should be placed down on the step first, followed by the injured leg, and then the good leg.
- C. The elbow should be straight when holding the cane.
- D. The cane should be held in the hand of the same side that needs support.
Correct Answer: B
Rationale: Downstairs, the cane and injured leg move first, followed by the good leg, ensuring stability. The cane is held opposite the injured side, with the elbow slightly bent, and reaches hip level.
The client's intravenous (IV) line has a gauze pad wrapped around the IV catheter at the insertion site and a transparent dressing over the gauze dressing. How long after application should the nurse change the dressing?
- A. At the normal rotation time for the IV.
- B. When the transparent dressing loosens.
- C. In 48 hours.
- D. In 24 hours.
Correct Answer: B
Rationale: Transparent dressings should be changed when they loosen (B) or per facility policy (typically every 5-7 days unless soiled or loose). Fixed intervals (C, D) or IV rotation (A) do not apply directly.