Nokea
The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid:
- A. Holding the infant
- B. Offering a pacifier
- C. Providing a mobile
- D. Offering sterile water
Correct Answer: B
Rationale: Offering a pacifier is contraindicated after cleft lip repair as it can disrupt the surgical site and impair healing.
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A client who was prescribed increasing dosages of baclofen to relieve muscle spasms should have taken 80 mg daily in 4 divided doses but misunderstood and took 80 mg four times a day, resulting in an overdose and pronounced CNS depression. Which of the following treatments does the nurse anticipate?
- A. Administration of naloxone.
- B. Administration of atropine.
- C. Supportive care only.
- D. Administration of flumazenil.
Correct Answer: C
Rationale: Baclofen overdose causes CNS depression, treated with supportive care (C) like ventilation and monitoring. Naloxone (A), atropine (B), and flumazenil (D) are not antidotes for baclofen.
A client requires long-term use of corticosteroids. The nurse explains which of the following is associated with chronic corticosteroid therapy?
- A. chronic fever
- B. inability to gain weight
- C. orthostatic hypotension
- D. osteoporosis
Correct Answer: D
Rationale: Chronic corticosteroid use causes osteoporosis due to bone density loss. Weight gain (not inability), not fever or hypotension, is more common.
The nurse is caring for a client who fractured her leg in a motor vehicle accident. A cast is applied. The nurse will assess which of the following? Select all that apply.
- A. pulses
- B. capillary refill
- C. skin temperature
- D. squeeze the cast every hour to check for firmness
- E. assess for pain, numbness, tingling, or inability to move the toes
Correct Answer: A, B, C, E
Rationale: Assessing pulses, capillary refill, skin temperature, and neurovascular symptoms (pain, numbness, tingling, movement) ensures circulation and nerve function are intact; squeezing the cast is inappropriate.
The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?
- A. Reluctance to swallow
- B. Drooling of blood-tinged saliva
- C. An axillary temperature of 99°F
- D. Respiratory stridor
Correct Answer: D
Rationale: Respiratory stridor post-tonsillectomy indicates airway obstruction, a life-threatening complication requiring immediate reporting.
The nurse is assisting in the care of a patient who is 2 days post-operative from a hemorrhoidectomy. The nurse would be correct in instructing the patient to:
- A. Avoid a high-fiber diet
- B. Continue to use ice packs
- C. Take a laxative daily to prevent constipation
- D. Use a sitz bath after each bowel movement
Correct Answer: D
Rationale: A sitz bath promotes healing and relieves pain after a hemorrhoidectomy by keeping the area clean and reducing inflammation.