Nokea
The nurse is reinforcing teaching about circumcision care with the parent of a newly circumcised newborn. Which statement by the parent would require follow-up?
- A. I should change my baby's diaper at least every 4 hours.
- B. I should notify the health care provider if there is odorous discharge from the site.
- C. I will apply light pressure with gauze if there is bleeding at the site.
- D. I will clean the site with alcohol-based wipes or soap and water.
Correct Answer: D
Rationale: Alcohol-based wipes are too harsh for a circumcision site; gentle soap and water are recommended, requiring follow-up. Other statements are correct.
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The nurse is caring for a client who has a prescription for nalbuphine 10 mg/70 kg subcutaneously once. The client weighs 187 lb (85 kg). The nurse has nalbuphine 10 mg/1 mL available. How many mL should the nurse administer to the client? Record your answer using 1 decimal place.
Correct Answer: 1.2
Rationale: Dose = (10 mg/70 kg) × 85 kg = 12.14 mg. Volume = 12.14 mg ÷ 10 mg/mL = 1.2 mL.
The nurse is caring for a client with histrionic personality disorder. Which of the following findings would the nurse expect to observe?
- A. Tries to intimidate others, lacks empathy, disregards rules, and avoids consequences
- B. Exhibits attention-seeking behaviors and is overly dramatic
- C. Is overly suspicious of others' intentions and socially withdrawn
- D. Exhibits persistent compulsive behaviors and rigid perfectionism
Correct Answer: B
Rationale: Histrionic personality disorder is characterized by attention-seeking and overly dramatic behaviors. The other options describe different personality disorders.
The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room? Select all that apply.
- A. Oral bite prevention device
- B. Oxygen delivery system
- C. Padding on the bed side rails
- D. Soft arm and leg restraints
- E. Suction equipment
Correct Answer: B,C,E
Rationale: Oxygen ensures adequate oxygenation during seizures, padding prevents injury from bed rails, and suction equipment clears airways if secretions accumulate. Oral bite devices are unsafe during seizures due to choking risks, and restraints are not typically used unless absolutely necessary.
The nurse is assessing a comatose client receiving gastric tube feedings. Which of the following assessments requires an immediate response from the nurse?
- A. Decreased breath sounds in right lower lobe
- B. Aspiration of a residual of 100 cc of formula
- C. Decrease in bowel sounds
- D. Urine output of 250 cc in past 8 hours
Correct Answer: A
Rationale: Decreased breath sounds in right lower lobe. The most common problem associated with enteral feedings is atelectasis. Maintain client at 30 degrees of head elevation during feedings and monitor for signs of aspiration. Check for tube placement prior to each feeding or every 4 to 8 hours if the client is receiving continuous feeding.
The nurse is caring for a client who has a C6 spinal cord injury. He complains of blurred vision and a severe headache. His blood pressure is 210/140. What action should the nurse take initially?
- A. Check for bladder distention
- B. Place in Trendelenburg position
- C. Administer PRN pain medication
- D. Continue to monitor blood pressure
Correct Answer: A
Rationale: Symptoms and hypertension suggest autonomic dysreflexia, often triggered by bladder distention in spinal cord injury. Checking and relieving distention is the initial action.