Nokea
The nurse is contributing to the plan of care for a client with diabetes who reports breast tenderness, vaginal discharge, and urinary frequency. Which action is most important to include in the plan of care?
- A. Ask if the client performs breast self-exams
- B. Ask the client about characteristics of vaginal discharge
- C. Determine the date of the client's last menstrual period
- D. Review the client's home blood sugar logs
Correct Answer: C
Rationale: Determining the date of the client's last menstrual period is critical to assess for pregnancy or menopausal changes, which could explain the symptoms and impact diabetes management. Breast self-exams and vaginal discharge characteristics are less urgent, and blood sugar logs, while important, are not directly related to the reported symptoms.
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A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m² (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine?
- A. Child's pattern of daily physical activity
- B. Family's eating habits
- C. Family's financial resources for purchasing healthy foods
- D. Family's readiness for change
Correct Answer: D
Rationale: The family's readiness for change is critical, as it determines their willingness to adopt and sustain lifestyle changes necessary for weight loss. While activity, eating habits, and finances are important, motivation drives success.
The mother of a 4 month-old infant asks the nurse about the dangers of sunburn while they are on vacation at the beach. Which of the following is the best advice about sun protection for this child?
- A. Use a sunscreen with a minimum sun protective factor of 15.'
- B. Applications of sunscreen should be repeated every few hours.'
- C. An infant should be protected by the maximum strength sunscreen.'
- D. Sunscreens are not recommended in children younger than 6 months.'
Correct Answer: D
Rationale: Infants under 6 months of age should be kept out of the sun or shielded from it. Even on a cloudy day, the infant can be sunburned while near water. A hat and light protective clothing should be worn.
The nurse is caring for a client with suspected tracheoesophageal fistula and esophageal atresia. The nurse is most likely to observe
- A. choking and cyanosis during feeding
- B. concave abdomen
- C. diminished lung sounds
- D. projectile vomiting after feeding
Correct Answer: A
Rationale: Tracheoesophageal fistula and esophageal atresia prevent normal swallowing, leading to pooling of saliva and excessive salivation. Abdominal distension or vomiting may occur in some cases, but salivation is the most consistent sign. Diminished lung sounds are less specific.
The most common cause of injury from a house fire is:
- A. explosion.
- B. falls from second-story windows.
- C. thermal damage to skin and body surfaces.
- D. inhalation injury.
Correct Answer: D
Rationale: Inhalation injury, from smoke and toxic gases, is the most common cause of house fire injuries, often leading to respiratory compromise. Thermal damage is also significant but less frequent. Accident Prevention
The nurse is performing a dressing change for a client with an infected wound. Which actions by the aide indicate adherence to appropriate infection control procedures? Select all that apply.
- A. Pull glove off over the soiled dressing to encase it before disposal
- B. Save unused sterile 4x4s by taping original package shut for the next dressing change
- C. Wash hands prior to putting on gloves and after removing them
- D. Wrap soiled dressing in paper towels before disposing of it in the trash can
Correct Answer: A,C
Rationale: Encasing the dressing in a glove and washing hands before and after glove use prevent contamination. Saving sterile supplies compromises sterility, and wrapping in paper towels before regular trash disposal risks infection spread; biohazard disposal is required.