Nokea
The nurse is discussing safety and accident prevention with the mother of a 9-month-old. The teaching has been effective when the mother states which of the following?
- A. I make sure that I keep my cleaning supplies locked up.'
- B. Sometimes she plays in the bathroom when I'm cleaning in there.'
- C. Occasionally she gets under the chair and plays with the telephone cord.'
- D. I've found that those child-protective cabinet locks don't work very well.'
Correct Answer: A
Rationale: Keeping cleaning supplies locked up indicates effective teaching on safety, as it prevents the child from accessing hazardous substances.
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The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which of the following in the future?
- A. Hearing problems.
- B. Speech defect.
- C. Chronic sinus infections.
- D. Tonsillitis.
Correct Answer: A, B
Rationale: Cleft palate repair increases the risk of hearing problems (due to Eustachian tube dysfunction) and speech defects.
You are working as a wound care nurse. You measure the size of a client's wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as:
- A. 6 cm
- B. 12 cm
- C. 20 cm
- D. 24 cm
Correct Answer: B
Rationale: Wound dimensions are documented as length x width x depth (2 cm x 4 cm x 3 cm), but the total linear measurement is not typically summed. However, based on the options, 12 cm may reflect a misinterpretation; the correct documentation is the individual measurements.
A nurse is assessing a client with a history of myocardial infarction who is in the surgical unit following a gastric resection. The client complains of chest pains. The nurse obtains the electrocardiogram (ECG) shown (see figure). What should the nurse do first?
- A. Administer oxygen.
- B. Inspect the client's incision.
- C. Call the rapid response team.
- D. Reposition the ECG electrodes.
Correct Answer: A
Rationale: Chest pain post-myocardial infarction suggests possible cardiac ischemia, so administering oxygen is the priority to improve oxygenation. The other actions follow after initial stabilization.
A client who has been recently diagnosed with unsuccessful immunodiffence (MIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:
- A. For clients with an inevitable death within weeks to months
- B. For all clients with AIDS at any stage
- C. Only for clients with cancer
- D. When the client is ready to discuss his prognosis
Correct Answer: A
Rationale: Hospice care is appropriate for clients with a terminal illness and a prognosis of weeks to months, regardless of the specific diagnosis. It is not limited to cancer or all AIDS stages, nor solely based on readiness to discuss prognosis.
A client with chronic renal failure is receiving hemodialysis. Which dietary restriction should the nurse emphasize?
- A. Low-protein diet.
- B. High-sodium diet.
- C. Low-potassium diet.
- D. High-calcium diet.
Correct Answer: C
Rationale: A low-potassium diet is critical in chronic renal failure to prevent hyperkalemia, which can cause cardiac complications.