Nokea
The nurse is teaching the mother of a newborn to care for the umbilical cord. What should the nurse advise the mother to do if the cord becomes soiled with urine or feces?
- A. Swab with alcohol.
- B. Wipe with a dry cloth.
- C. Wash with mild soap and water, rinse and dry.
- D. Swab with povidone-iodine.
Correct Answer: C
Rationale: Washing with mild soap and water, rinsing, and drying (C) cleans the umbilical cord safely without irritation. Alcohol (A) and povidone-iodine (D) may be too harsh, and a dry cloth (B) is ineffective.
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The nurse should visit which of the following clients first?
- A. The client with diabetes with a blood glucose of 95 mg/dL
- B. The client with hypertension being maintained on Lisinopril
- C. The client with chest pain and a history of angina
- D. The client with Raynaud's disease
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible cardiac ischemia, requiring immediate assessment.
The nurse is caring for a client diagnosed with glaucoma. The health care provider has ordered timolol maleate. Which finding in the client's history would prompt the nurse to notify the health care provider?
- A. asthma
- B. migraines
- C. atrial fibrillation
- D. urinary tract infection
Correct Answer: A
Rationale: Timolol, a beta-blocker, can exacerbate asthma by causing bronchoconstriction. Other conditions are not contraindications.
The home health nurse is visiting a client who plans to deliver her baby at home. Which statement by the client indicates an understanding regarding screening for phenylketonuria (PKU)?
- A. I will need to take the baby to the clinic within 24 hours of delivery to have blood drawn.
- B. I will need to schedule a home visit for PKU screening when the baby is 3 days old.
- C. I will remind the midwife to save a specimen of cord blood for the PKU test.
- D. I will have the PKU test done when I take her for her first immunizations.
Correct Answer: B
Rationale: PKU screening is typically performed at 2-3 days of age to ensure accurate results, as earlier testing may yield false negatives.
A client diagnosed with lung cancer asks the nurse what the term MO refers to. The nurse says that MO means
- A. no distant metastasis present.
- B. distant metastasis present.
- C. distant metastasis cannot be evaluated.
- D. metastasis present only in immediate lymph nodes.
Correct Answer: A
Rationale: In cancer staging, M0 indicates no distant metastasis, per TNM classification.
The nurse is caring for a client with a history of spinal cord injury who is admitted with a urinary tract infection. Which of the following interventions should the nurse implement?
- A. Encourage the client to limit fluid intake.
- B. Administer antibiotics as ordered.
- C. Insert an indwelling catheter.
- D. Restrict the client to bed rest.
Correct Answer: B
Rationale: antibiotics are the primary treatment for a urinary tract infection