The nurse is caring for clients in outpatient surgery.
- A. What is the best statement by the nurse to the mother of a four-year-old preparing for eye surgery?
- B. Draw a picture of the eye to explain what will happen.'
- C. Tell your daughter that the procedure will take one hour.'
- D. Use dolls or puppets to explain how to get ready for surgery.'
- E. Read an age-appropriate illustrated book about eye surgery to your daughter.'
Correct Answer: C
Rationale: For a four-year-old, using dolls or puppets to demonstrate the procedure in simple terms is developmentally appropriate, addressing what the child will experience (see, hear, feel). Drawing pictures or reading books is better for school-aged children, and time concepts like one hour are not relatable to preschoolers.
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The nurse discovers that a hospitalized client is not breathing and has no pulse. After calling for help, what should the nurse do next?
- A. Give the client two breaths
- B. Administer five chest compressions
- C. Go get the emergency cart
- D. Defibrillate the client
Correct Answer: A
Rationale: Per CPR guidelines, after calling for help, provide two rescue breaths if trained, followed by compressions. Fetching the cart or defibrillating delays resuscitation.
A client is admitted with a tentative diagnosis of bladder cancer. Which finding most likely contributed to the development of bladder cancer?
- A. Two PPD cigarette use for 25 years
- B. Frequent urinary tract infections
- C. Employment in the textile industry
- D. A history of renal calculi
Correct Answer: A
Rationale: Cigarette smoking is a significant risk factor for bladder cancer due to the exposure to carcinogenic chemicals excreted in urine. Answer A (two packs per day for 25 years) is the most likely contributor. Answers B, C, and D are less directly associated with bladder cancer development.
The nurse's aide comes to take a woman by wheelchair for a magnetic resonance imaging (MRI) scan of the head and neck.
Which of the following observations, if made by the nurse, would require an intervention?
- A. The woman removes her dentures and gives them to her husband.
- B. The woman's vital signs are: BP 120/70, pulse 80, respirations 12, temperature 99°F (37.3°C).
- C. The woman has a nitroglycerine patch on her right chest area.
- D. The woman has red nail polish on her fingers and toes.
Correct Answer: C
Rationale: Strategy: 'Require an intervention' indicates an incorrect action. (1) should be removed before the Test (2) results are within normal limits (3) correct-should be removed before the Test (4) unnecessary to check capillary refill
A client diagnosed with chronic depression is maintained on tranylcypromine (Parnate). An important nursing intervention is to teach the client to avoid which of the following foods?
- A. Wine, beer, cheese, liver and chocolate
- B. Wine, citrus fruits, yogurt and broccoli
- C. Beer, cheese, beef and carrots
- D. Wine, apples, sour cream and beef steak
Correct Answer: A
Rationale: These foods are tyramine-rich and ingestion of these foods while taking monoamine oxidase inhibitors (MAOIs) can precipitate a life-threatening hypertensive crisis.
The nurse is administering alendronate (Fosamax) to an adult. Which instruction is necessary to give the client?
- A. Take medication with milk and a snack.
- B. Take medication after each meal.
- C. Sit up for at least 30 minutes after taking medication.
- D. Lie down for 30 minutes after taking medication.
Correct Answer: C
Rationale: Alendronate can cause esophageal irritation; sitting up for 30 minutes post-dose ensures proper passage and absorption, preventing reflux. Milk, meals, or lying down increase irritation risk.
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