Nokea
The nurse is providing pin site care for an adult who is in skeletal traction. What should the nurse do when providing pin site care?
- A. Clean the pin site with alcohol
- B. Clean the pin site with hydrogen peroxide
- C. Clean the pin site with betadine and apply steroid ointment as ordered
- D. Clean the pin site with soap and water and apply antibiotic ointment as ordered
Correct Answer: D
Rationale: Pin site care involves cleaning with soap and water to prevent infection and applying antibiotic ointment as ordered to reduce bacterial growth, per standard protocols.
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The client is scheduled for a glucose tolerance test. Place in ordered response the correct sequence for performance of this test.
- A. Instruct the client to drink a 75 gm glucose solution.
- B. Tell the client to eat a high carbohydrate diet for three days prior to the exam.
- C. Instruct the client to remain NPO after midnight.
- D. Obtain a fasting blood glucose level.
- E. Obtain a two-hour post-prandial glucose level.
Correct Answer: B,C,D,A,E
Rationale: When placing in chronological order, the nurse should: tell the client to increase the amount of carbohydrates for three days prior to the exam; instruct the client to remain NPO after midnight the day of the exam; obtain a fasting blood glucose level; instruct the client to drink a 75 gm glucose solution; and obtain a two-hour post-prandial glucose level. The candidate is asked to place answers in a logical sequence. Think about the natural order of the question.
Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?
- A. Offer several choices to the client.
- B. Give simple directions to the client.
- C. Give the client the details of the care.
- D. Offer written instructions to the client.
Correct Answer: B
Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.
While collecting data from pregnant clients in the obstetric clinic, the nurse should alert the health care provider to see which client first?
- A. First-trimester client who reports frequent nausea and vomiting
- B. Second-trimester client with dysuria and urinary frequency
- C. Second-trimester client with obesity who reports decrease in fetal movement
- D. Third-trimester client with right upper quadrant pain and nausea
Correct Answer: C
Rationale: Decreased fetal movement in the second trimester suggests potential fetal distress, requiring urgent evaluation. Nausea, UTI symptoms, and third-trimester pain are concerning but less immediately critical.
The nurse has taught the parent of a 6-year-old client with bacterial conjunctivitis how to administer ophthalmic medications. Which of the following statements by the parent would indicate a correct understanding of the teaching?
- A. My child should look down at the floor while I administer the eye drops.
- B. My child should squeeze the eyes closed after I administer the eye drops.
- C. I will apply firm pressure to my child's eyes after I administer the eye ointment
- D. I will apply the eye ointment along my child's lower eyelids starting at the inner corner of the eyes
Correct Answer: D
Rationale: Appropriate administration of ophthalmic medications (eg, eye drops, ointments) protects eye structures and ensures appropriate distribution across the eye. Ophthalmic ointment should be administered along the lower eyelid, moving from the inner canthus to the outer canthus (inner corner to outer corner) (Option 4). In addition, the medication package (eg, eye dropper, tube of ointment) must not touch the eyes to prevent contamination.
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct Answer: A
Rationale: Unequal leg length. Shortening of the affected leg is a sign of developmental dysplasia of the hip.