Nokea
The nurse is teaching circumcision care to the mother of a newborn. Which statement indicates that the mother needs further teaching?
- A. I will apply a petroleum gauze to the area with each diaper change.
- B. I will clean the area carefully with each diaper change.
- C. I can place a heat lamp to the area to speed up the healing process.
- D. I should carefully observe the area for signs of infection.
Correct Answer: C
Rationale: Using a heat lamp is incorrect and could cause burns or delay healing. Petroleum gauze, cleaning, and monitoring for infection are appropriate circumcision care practices.
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A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which recommendation is most appropriate?
- A. Limit exercise to once a week.
- B. Reduce sodium intake.
- C. Increase caffeine consumption.
- D. Avoid stress management techniques.
Correct Answer: B
Rationale: Reducing sodium intake lowers blood pressure in hypertension by decreasing fluid retention. Exercise should be regular, caffeine avoided, and stress management encouraged.
The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?
- A. A client who is a diabetic with a foot ulcer
- B. A client with a deep vein thrombosis receiving intravenous heparin
- C. A client being weaned from a tracheostomy
- D. A post-operative cholecystectomy with a T-tube
Correct Answer: A
Rationale: A diabetic with a foot ulcer is stable and suitable for an LPN, who can perform wound care and monitoring. Heparin infusion (B), tracheostomy weaning (C), and T-tube management (D) require RN-level skills due to complexity and risk.
Which of the following symptoms might the nurse observe in a client with a lithium blood level over 2.0?
- A. Fine hand tremor, headache, mental dullness
- B. Vomiting, impaired consciousness, decreased blood pressure
- C. Polyuria, polydipsia, edema
- D. Gastric irritation, nausea, diarrhea
Correct Answer: B
Rationale: These symptoms of lithium toxicity are usually dose related.
A client is admitted with disseminated herpes zoster (shingles). According to the Centers for Disease Control Guidelines for Infection Control:
- A. Airborne precautions will be needed.
- B. No special precautions will be needed.
- C. Only contact precautions will be needed.
- D. Droplet precautions will be needed.
Correct Answer: A
Rationale: Disseminated herpes zoster requires airborne precautions because the varicella-zoster virus can spread through respiratory droplets in immunocompromised patients.