Nokea
The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
- A. Explain that the procedure will help him to get well
- B. Show a cartoon character with a blood pressure cuff
- C. Explain that the blood pressure checks the heart pump
- D. Permit handling the equipment before putting the cuff in place
Correct Answer: D
Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
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The nurse is reinforcing skin care guidelines for a client who is receiving external radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I will apply an ice pack to the treatment site if my skin begins to burn.
- B. I will rub baby oil on the site after each treatment to prevent dry skin.
- C. I will use extra measures to protect my skin from sun exposure.
- D. I will wash the treatment site with lukewarm water and mild soap.
- E. I will wear soft, loose-fitting clothing.
Correct Answer: C,D,E
Rationale: Sun protection (C), gentle washing (D), and loose clothing (E) are correct for radiation therapy skin care. Ice packs (A) can damage skin, and baby oil (B) may irritate or trap radiation.
The best position for the client with a right total hip replacement is:
- A. With the right hip flexed 90°
- B. With the right hip flexed 35°
- C. Supine with pillows supporting the right leg
- D. Sims position with the right leg adducted
Correct Answer: C
Rationale: Supine with pillows supporting the leg prevents dislocation while maintaining alignment. Flexion or adduction risks complications.
A nurse who is evaluating a developmentally challenged 2 year-old should stress which goal when talking to the child's mother?
- A. Teaching the child self care skills
- B. Preparing for independent toileting
- C. Promoting the child's optimal development
- D. Helping the family decide on long term care
Correct Answer: C
Rationale: Promoting the child's optimal development. The primary goal is to promote the child's optimum development.
The nurse is teaching a client newly diagnosed with asthma how to use the metered-dose inhaler (MDI). The client asks when they will know the canister is empty. The best response is
- A. Drop the canister in water to observe floating
- B. Estimate how many doses are usually in the canister
- C. Count the number of doses as the inhaler is used
- D. Shake the canister to detect any fluid movement
Correct Answer: A
Rationale: Dropping the canister into a bowl of water assesses the amount of medication remaining in a metered-dose inhaler. The client should obtain a refill when the inhaler rises to the surface and begins to tip over.
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
Correct Answer: B
Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.