Nokea
The nurse is observing a student gauss administering ear drops to a two-year-old. Which observation by the nurse would indicate correct technique?
- A. Holds the child's head up and extended
- B. Places the head in chin-tuck position
- C. Pulls the pinna down and back
- D. Irrigates the ear before administering medication
Correct Answer: C
Rationale: Pulling the pinna down and back in children straightens the ear canal for proper ear drop administration. Head extension (A), chin-tuck (B), and irrigation (D) are incorrect.
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The client is admitted with a diagnosis of acute glomerulonephritis. Which assessment finding is most expected?
- A. Hematuria
- B. Hypotension
- C. Weight loss
- D. Clear urine
Correct Answer: A
Rationale: Hematuria is a hallmark of acute glomerulonephritis due to glomerular inflammation and damage, leading to blood in the urine. Hypertension, weight gain, and oliguria are more common than hypotension, weight loss, or clear urine.
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Only contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.
A six-month-old infant is receiving ribavirin for the treatment of respiratory syncytial virus. Ribavirin is administered via which one of the following routes?
- A. Oral
- B. IM
- C. IV
- D. Aerosol
Correct Answer: D
Rationale: Ribavirin is not supplied in an oral form. Ribavirin is administered by aerosol in order to decrease the duration of viral shedding within the infected tissue. Ribavirin is not approved for IV use to treat respiratory syncytial virus. Ribavirin is a synthetic antiviral agent supplied as a crystalline powder that is reconstituted with sterile water. A Small Aerosol Particle Generator unit aerosolizes the medication for delivery by oxygen hood, croup tent, or aerosol mask.
The elderly client is being discharged following a total knee replacement. To facilitate independence, the nurse should instruct the client/family to do which of the following?
- A. Use an elevated commode seat.
- B. Remove throw rugs from the floor.
- C. Install grab bars in the bathroom.
- D. Wear a medic alert monitor.
- E. Leave the nightlight on during resting hours.
- F. Apply foot protectors to the heels.
- G. Place the walker at the bedside.
Correct Answer: A, B, C, D, E, G
Rationale: Elevated commode seats (A), removing rugs (B), grab bars (C), medic alert monitors (D), nightlights (E), and bedside walkers (G) promote safety and independence. Foot protectors (F) are unrelated to mobility, and elevated side rails (H) may trap the client, increasing fall risk.
The nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most indicative?
- A. Bilateral leg edema
- B. Warm, red, swollen calf
- C. Mild leg cramping
- D. Pale, cool foot
Correct Answer: B
Rationale: A warm, red, swollen calf is a classic sign of DVT due to clot-related inflammation. Bilateral edema (A) suggests heart failure, cramping (C) is nonspecific, and pale/cool foot (D) indicates arterial occlusion.