Nokea
The nurse is conducting discharge teaching to an adolescent with a methicillin-resistant Staphylococcus aureus (MRSA) infection. What should the nurse include in the instructions?
- A. Avoid sharing of towels and washcloths
- B. All are applicable
- C. Use bleach when laundering towels and washcloths
- D. Take a daily bath or shower with an antibacterial soap
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The clinic nurse is reviewing the immunization guidelines for hepatitis B. Which are true of the guidelines for this vaccine?
- A. The hepatitis B vaccination series should be begun at birth
- B. All are applicable
- C. Any child not vaccinated at birth should receive two doses at least 4 months apart
- D. An unimmunized 10-year-old child should receive three doses administered 4 weeks apart
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A new parent, when asked by a nurse, explains that the 4-month-old infant has been nursing regularly every 3 to 4 hours and seems satisfied. However, the parent recently introduced solid food in the form of unbuttered popcorn to the infant as a supplement. What should be the primary nursing concern in this situation?
- A. Imbalanced nutrition, more than body requirements, related to introduction of a high-calorie food
- B. Risk for aspiration related to feeding the infant an inappropriate food
- C. Imbalanced nutrition, less than body requirements, related to introduction of a low-nutritive food
- D. Readiness for enhanced nutrition, related to the age of the infant
Correct Answer: B
Rationale: The primary nursing concern in this situation is the risk for aspiration. Popcorn is a choking hazard for infants, as their airway is not fully developed to handle solid foods like popcorn. Choices A, C, and D are incorrect because the main focus should be on the immediate risk of aspiration due to the inappropriate solid food given to the infant, rather than on nutritional imbalances or readiness for enhanced nutrition.
What approach is the most appropriate when performing a physical assessment on a toddler?
- A. Demonstrate the use of equipment
- B. Perform traumatic procedures last
- C. Use minimum physical contact initially
- D. Always proceed systematically in a head-to-toe direction
Correct Answer: C
Rationale: The most appropriate approach when performing a physical assessment on a toddler is to use minimum physical contact initially. This helps gain the toddler's cooperation and reduces their distress. Performing traumatic procedures last is crucial as they are likely to upset the child and should be handled with care. Demonstrating the use of equipment may be complex for toddlers to understand, so it is not the most appropriate initial approach. Proceeding systematically in a head-to-toe direction is a good practice but using minimum physical contact initially is more important to establish trust and cooperation with the toddler.
What is a common significant side effect of opioid administration?
- A. Euphoria
- B. Diuresis
- C. Constipation
- D. Allergic reactions
Correct Answer: C
Rationale: Constipation is one of the most common side effects of opioid administration due to the slowing down of gastrointestinal motility. Opioids affect the bowel movements, leading to constipation. Euphoria, while a possible effect, is less common than constipation. Diuresis is not a typical side effect of opioids; instead, urinary retention may occur. Allergic reactions are rare side effects of opioids, with symptoms such as rash, itching, or anaphylaxis.
At which age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?
- A. 1 month
- B. 2 months
- C. 3 months
- D. 4 months
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.