Nokea
The nurse is collecting data from a 30-month-old client. Which of the following findings would require follow-up?
- A. head circumference has increased by 1 inch (2.5 cm) in the past year
- B. current weight is six times greater than birth weight
- C. nighttime bladder control has not been achieved
- D. anterior and posterior fontanels are both fused
Correct Answer: C
Rationale: Lack of nighttime bladder control at 30 months may indicate developmental delay or medical issues, requiring follow-up to assess for underlying causes.
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An adult client is receiving oxygen at 6 L/min. The client asks the nurse why the oxygen is running through bubbling water. What should be included in the nurse's reply?
- A. The water cools the oxygen and makes it more comfortable.
- B. Oxygen is very drying to tissues; the water humidifies it.
- C. The water prevents fires when oxygen is in use.
- D. The water helps to prevent infections from developing in the tubing.
Correct Answer: B
Rationale: Bubbling water in oxygen delivery systems humidifies the oxygen, preventing mucosal drying. It doesn't cool oxygen, prevent fires, or reduce infections.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- A. Syphilis
- B. Herpes
- C. Gonorrhea
- D. Condylomata
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.
The nurse has an order to administer ophthalmic drops and ophthalmic ointment to a client being treated for conjunctivitis. The nurse should:
- A. Apply the eye ointment and eye drops together.
- B. Apply the eye drops, wait 5 minutes, and apply the ointment.
- C. Apply the eye ointment, wait 30 minutes, and apply the eye drops.
- D. Ask the pharmacist to supply the two medications in the same form.
Correct Answer: B
Rationale: Applying drops first, then waiting 5 minutes before ointment, ensures proper absorption of both. Ointment first would block drops, and combining forms is unnecessary.
The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?
- A. Avoid climbing stairs for 3 months
- B. Ambulate using crutches only
- C. Sleep in a supine position only
- D. Do not cross your legs
Correct Answer: D
Rationale: Do not cross your legs. Crossing legs can exceed the 90-degree hip flexion limit, risking dislocation.
A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?
- A. Fresh juice, carrots, vanilla pudding
- B. Apple juice, ham salad, fresh pineapple
- C. Hamburger, fries, strawberry shake
- D. Red wine, fava beans, aged cheese
Correct Answer: D
Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.