Nokea
The nurse is teaching a community group about how to prevent Lyme disease. What should be included in the teaching? Select all that apply.
- A. Wear dark-colored clothing when outdoors.
- B. Tuck long pants inside socks.
- C. Wear long sleeves and long pants when outside.
- D. Remove standing water.
- E. Use insect repellant containing DEET.
- F. Do not eat venison.
Correct Answer: B,C,E
Rationale: Tucking pants into socks, wearing long clothing, and using DEET repel ticks, preventing Lyme disease. Light clothing aids tick visibility, standing water is irrelevant, and venison is safe.
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During auscultation of the fetal heart rate during labor, the nurse assesses a rate of 59 beats per minute.
The FIRST action the nurse should take is
- A. turn the mother on her right side, increase the intravenous flow rate, and call the physician.
- B. turn the mother on her left side, administer oxygen by nasal cannula, and start an IV.
- C. call the physician, and make preparations for an immediate emergency cesarean section.
- D. position the mother in Trendelenburg's position, administer oxygen, and force fluids.
Correct Answer: B
Rationale: Strategy: 'FIRST' indicates that this is a priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) should be placed on left side to increase blood flow to the uterus (2) correct-persistent fetal bradycardia may indicate cord compression or separation of the placenta, but always indicates fetal distress, left side reduces compression of vena cava and aorta (3) should be done after positioning patient (4) this position is used only if there is cord prolapsed
A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to
- A. Administer pain medication
- B. Suction excessive tracheobronchial secretions
- C. Assist client to turn, deep breathe and cough
- D. Monitor oxygen saturation
Correct Answer: B
Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.
Which laboratory result would be expected during the emergent phase of a burn injury?
- A. Glucose 100 mg/dl
- B. Potassium 3.5 mEq/l
- C. Sodium 142 mEq/l
- D. Albumin 4.2 gm/dl
Correct Answer: A
Rationale: Glucose levels rise as a result of the stress response during the emergent phase. Answers B, C, and D are within normal range. K+ and Na+ would be elevated, whereas albumin would be lowered during the emergent period due to increased permeability.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Creatinine 2.5 mg/dL.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A creatinine of 2.5 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.