Nokea
The nurse is teaching the mother of an infant with eczema. Which of the following instructions should be included in the nurse's teaching?
- A. Dress the infant warmly to prevent undue chilling
- B. Cut the infant's fingernails and toenails regularly
- C. Use bubble bath instead of soap for bathing
- D. Wash the infant's clothes with mild detergent and fabric softener
Correct Answer: B
Rationale: Cutting nails regularly prevents scratching, which can worsen eczema and lead to infections in affected skin areas.
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A client's admission history reveals complaints of fatigue, chronic sore throat, and enlarged lymph nodes in the axilla and neck. Which exam would assist the physician to make a tentative diagnosis of leukemia?
- A. A complete blood count
- B. An x-ray of the chest
- C. A bone marrow aspiration
- D. A CT scan of the abdomen
Correct Answer: A
Rationale: A complete blood count (CBC) is the initial test for leukemia, revealing abnormal white blood cell counts, anemia, or thrombocytopenia, supporting a tentative diagnosis.
The nurse is developing a plan of care for a client with an ileostomy. The priority nursing diagnosis is:
- A. Fluid volume deficit
- B. Alteration in body image
- C. Impaired oxygen exchange
- D. Alteration in elimination
Correct Answer: A
Rationale: Fluid volume deficit is the priority due to the risk of dehydration from high ileostomy output, which can lead to electrolyte imbalances and other complications.
A 19-year-old female comes into the women's clinic for an STD test. The nurse explains all of the following confirmed cases of STDs must be reported to the Centers for Disease Control (CDC) EXCEPT
- A. genital herpes.
- B. chlamydia.
- C. hepatitis B.
- D. gonorrhea.
Correct Answer: A
Rationale: Chlamydia, gonorrhea, and hepatitis B are reportable to the CDC. Genital herpes is not nationally reportable, though local regulations may vary.
An end-of-life client receiving home hospice care states he no longer wants to eat. The nurse should
- A. speak with the health care provider about inserting a feeding tube.
- B. encourage the client to eat small, nutritious meals.
- C. accept the client's decision and work to make the client comfortable.
- D. ask the client's family to bring the client's favorite foods.
Correct Answer: C
Rationale: In hospice care, respecting the client’s autonomy is key. Accepting the decision to stop eating and focusing on comfort aligns with end-of-life care principles.
The nurse is caring for a 9-year-old child admitted with asthma. Upon the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
- A. Notify the physician
- B. Do nothing; this is a normal O2 sat for a 9-year-old
- C. Apply oxygen
- D. Assess the child's pulse
Correct Answer: C
Rationale: An O2 sat of 78% indicates severe hypoxemia, so applying oxygen is the first action to stabilize the child.