Nokea
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
- A. Change the pillow covers every month
- B. Wash bed linens in warm water with a cold rinse
- C. Wash and rinse the bed linens in hot water
- D. Use air filters in the furnace system
Correct Answer: C
Rationale: Wash and rinse the bed linens in hot water. For asthma clients sensitive to house dust-mites, washing bed linens in hot water above 130 degrees Fahrenheit is necessary to kill dust-mites.
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A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care?
- A. Weighing the client after she eats
- B. Having a staff member remain with her for 1 hour after she eats
- C. Placing high-protein foods in the center of the client's plate
- D. Providing the client with child-sized utensils
Correct Answer: B
Rationale: Having a staff member stay with the client for 1 hour after eating prevents purging, a common behavior in anorexia nervosa.
During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?
- A. Mongolian spots are a normal finding in dark-skinned children.'
- B. Port wine stains are often associated with other malformations.'
- C. Telangiectatic nevi are normal and will disappear as the baby grows.'
- D. The child is too young for consideration of surgical removal of these at this time.'
Correct Answer: C
Rationale: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years.
Which client should receive a private room?
- A. A client with diabetes
- B. A client with Cushing's disease
- C. A client with Graves' disease
- D. A client with gastric ulcers
Correct Answer: D
Rationale: A client with gastric ulcers may have Helicobacter pylori infection, which can be contagious and requires isolation precautions. Clients with diabetes, Cushing's disease, or Graves' disease do not typically require private rooms unless they have a contagious condition.
A client with acute leukemia has developed oral ulcerations. The nurse can increase the client's comfort by suggesting that he:
- A. Avoid brushing his teeth until the ulcers heal.
- B. Rinse his mouth frequently with normal saline.
- C. Rinse his mouth frequently with hydrogen peroxide.
- D. Cleanse his teeth and mouth with lemon and glycerin swabs.
Correct Answer: B
Rationale: Normal saline rinses are gentle and help keep the mouth clean without irritating oral ulcerations.
An adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also.adult is admitted to the emergency room with a laceration on the forearm and BP=140/74, P=110, and R=36. The client also complains of tingling around the mouth and in the fingers and toes. What should the nurse expect to do initially?
- A. Administer oxygen
- B. Have the client breathe into a paper bag
- C. Call the physician immediately
- D. Encourage the client to do deep breathing exercises
Correct Answer: B
Rationale: Tachypnea and tingling suggest hyperventilation causing respiratory alkalosis; breathing into a paper bag restores CO2 levels, correcting pH.