Nokea
The nurse is reinforcing teaching about foot care for a group of clients with diabetes mellitus. Which of the following information should the nurse include? Select all that apply.
- A. Dry the feet vigorously with a towel after bathing
- B. Use an over-the-counter kit to treat corns and calluses
- C. Use cotton or lamb’s wool to separate overlapping toes
- D. Wash the feet with lukewarm water
- E. Wear hard-sole shoes and do not go barefoot
Correct Answer: C,D,E
Rationale: Using cotton/wool for toes prevents pressure sores, lukewarm water avoids burns, and hard-sole shoes protect feet. Vigorous drying risks skin breakdown, and over-the-counter kits can cause injury in diabetic feet with poor sensation.
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What nursing action is essential when oxygen is ordered for a client who is living at home?
- A. Assist the client and family in checking all electrical appliances in the vicinity for frayed cords.
- B. Encourage the client and family to purchase fire extinguishers.
- C. Remove electrical devices from the room where oxygen is in use.
- D. Encourage the client and family to carpet the client's room.
Correct Answer: A
Rationale: Checking for frayed cords reduces fire risk, as oxygen supports combustion. Extinguishers are secondary, removing devices is impractical, and carpeting increases static sparks.
The charge nurse is reviewing events that staff nurses experienced during the shift. Which events require an incident/occurrence report to be completed? Select all that apply.
- A. Client determined brain dead was taken off life support
- B. Client with alcohol intoxication physically assaulted a nurse
- C. Serum troponin level was prescribed but never obtained
- D. Staff nurse did not present for work and did not notify management
- E. Visitor fell and refused care in the emergency department
Correct Answer: B,C,D
Rationale: Assault, missed lab tests, and staff no-show are reportable incidents due to safety, care quality, and staffing issues. Brain death withdrawal follows protocol, and a visitor’s fall with refused care is less reportable.
The nurse is caring for a 7-month-old client who has suspected bacterial meningitis. The nurse should first check the client’s
- A. anterior fontanel
- B. bilateral hearing
- C. pulse pressure
- D. Babinski reflex
Correct Answer: A
Rationale: A bulging anterior fontanel in a 7-month-old indicates increased intracranial pressure, a critical sign of meningitis requiring immediate attention. Hearing, pulse pressure, and Babinski reflex are less urgent.
When interviewing the parents of a child with asthma, it is most important to assess the child's environment for what factor?
- A. Household pets
- B. New furniture
- C. Lead based paint
- D. Plants such as cactus
Correct Answer: A
Rationale: Animal dander is a very common allergen affecting persons with asthma. Other triggers may include pollens, carpeting and household dust.
The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?
- A. Eliminate green, leafy, vitamin K-rich vegetables from your diet
- B. Mild bruising or redness may occur at the injection site
- C. You can take over-the-counter drugs such as ibuprofen to relieve mild discomfort
- D. You will need PT/INR assessments at regular intervals while on enoxaparin therapy
Correct Answer: B
Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.