Nokea
The nurse is talking with a client with rheumatoid arthritis who has a new prescription for adalimumab. Which of the following statements by the client would require follow-up?
- A. I usually take naproxen for pain twice a week
- B. I received my annual influenza vaccine injection 3 weeks ago.
- C. I received a negative test result for my tuberculin skin test one week ago.
- D. I started a course of antibiotic therapy to treat a urinary tract infection 2 days ago.
Correct Answer: D
Rationale: Adalimumab, an immunosuppressant, increases infection risk. Starting antibiotics for an active infection requires follow-up to ensure the infection is resolved before initiating adalimumab. The other statements are not concerning.
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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.
A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse?
- A. Encourage the parent to be involved with the child
- B. Engage in physical contact by removing the toddler's outer clothing first
- C. Have medical equipment lying on a counter within view
- D. Perform an examination in a head-to-toe order
Correct Answer: A
Rationale: Parental involvement reduces toddler anxiety during exams. Removing clothing first, visible equipment, or strict head-to-toe order may increase distress.
An adult is receiving intermittent tube feedings. When the nurse aspirates and measures the gastric contents, the client's wife asks the nurse what she is doing. What information is most important to include in the response?
- A. The procedure is done to test that the tube is working.
- B. The procedure is done to check the placement of the tube.
- C. The procedure is done to check for gastric emptying.
- D. The procedure is done to clear the line.
Correct Answer: B
Rationale: Aspirating gastric contents verifies tube placement, the most critical step to prevent aspiration during feedings.
The nurse is caring for a client born at 42 weeks gestation. Which of the following potential clinical findings should the nurse anticipate for a postterm newborn? Select all that apply.
- A. Deep plantar creases
- B. Dry, cracked, peeling skin
- C. Lanugo on the extremities
- D. Long fingernails and scalp hair
- E. Minimal or absent vernix
Correct Answer: A,B,D,E
Rationale: Postterm newborns often have deep plantar creases, dry/peeling skin, long nails/hair, and minimal vernix due to prolonged gestation. Lanugo is more common in preterm infants.
The nurse is talking with a client's spouse who insists on being present in the room while the client is receiving CPR. Which of the following actions should the nurse take?
- A. Call security to escort the spouse to the waiting room.
- B. Let the spouse stay and assign a staff member to explain the situation.
- C. Allow the spouse to stay in the room but out of sight of the resuscitation efforts.
- D. Inform the spouse that family members are not allowed in a client's room during emergency situations.
Correct Answer: B
Rationale: Allowing the spouse to stay with a staff member to explain reduces distress and supports family presence, which is often permitted during CPR.