Nokea
The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention?
- A. Administer oxygen via nasal cannula for client comfort and safety
- B. Clean area with povidone iodine in a circular motion moving outward
- C. Hold the child with the head and knees tucked in and the back rounded out
- D. Monitor and record vital signs every 15 minutes throughout the procedure
Correct Answer: C
Rationale: During a lumbar puncture for an infant, holding the child in a flexed position with head and knees tucked and back rounded ensures proper spinal alignment for safe needle insertion. Oxygen is not routinely needed, cleaning is typically done by the provider, and vital sign monitoring is important but not the primary intervention.
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The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?
- A. Insert an indwelling catheter
- B. Have the client void
- C. Keep the client NPO
- D. Administer an enema
Correct Answer: B
Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.
A nurse in a school health clinic is reinforcing teaching for the parent of a young client with pediculosis capitis. Which statement by the parent indicates understanding of the teaching?
- A. I will launder recently worn clothing, sheets, and towels in hot water.'
- B. I will make sure all eating utensils are placed in the dishwasher.'
- C. I will spray the house with insecticide to control this problem.'
- D. I will throw away stuffed animals and toys that cannot be washed.'
Correct Answer: A
Rationale: Laundering clothing, sheets, and towels in hot water effectively kills lice and nits, indicating understanding. Dishwashing utensils is irrelevant, spraying insecticide is unnecessary, and discarding toys is excessive if they can be sealed or washed.
A client who has congestive heart failure is being admitted. How should the nurse position this client?
- A. Supine
- B. Sims'
- C. Semi-sitting
- D. Side-lying
Correct Answer: C
Rationale: Semi-sitting (Fowler's position) reduces cardiac workload and improves breathing in congestive heart failure by decreasing venous return.
The nurse in the emergency department is caring for a client who sustained blunt force head trauma and is experiencing blurry vision. The nurse should suspect the client has sustained injury to the
- A. temporal lobe
- B. occipital lobe
- C. parietal lobe
- D. frontal lobe
Correct Answer: B
Rationale: Blurry vision post-head trauma suggests injury to the occipital lobe , which processes visual information. Temporal , parietal , and frontal lobes manage other functions.
The licensed practical nurse (LPN) is assisting the registered nurse in caring for 4 clients. Which client is at greatest risk for the development of deep venous thrombosis?
- A. 25-year-old client with abdominal pain who smokes cigarettes and takes oral contraceptives
- B. 55-year-old ambulatory client with exacerbation of chronic bronchitis and an elevated hematocrit level
- C. 72-year-old client who had coronary stent placement 2 days ago and has an elevated temperature
- D. 80-year-old client who had surgical repair of a fractured hip 4 days ago
Correct Answer: D
Rationale: An 80-year-old post-hip surgery client is at highest DVT risk due to age, immobility, and recent surgery. Smoking and contraceptives , elevated hematocrit , and stent with fever carry risks but are less immediate.