Nokea
The nurse is to open a sterile package. How should the nurse plan to open the first flap?
- A. Toward the nurse
- B. Away from the nurse
- C. To the right side
- D. To the left side
Correct Answer: B
Rationale: Opening the first flap away from the nurse maintains sterility by preventing hands from passing over the sterile field. Opening toward the nurse or to the sides risks contamination.
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The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?
- A. The first of every month, because it is easiest to remember'
- B. Right after the period, when your breasts are less tender'
- C. Do the exam at the same time every month'
- D. Ovulation, or mid-cycle is the best time to detect changes'
Correct Answer: B
Rationale: The best time for a breast self-exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.
The nurse is caring for a client with a history of renal failure.
- A. Which laboratory finding is most concerning for a client with chronic renal failure?
- B. Serum creatinine of 2.5 mg/dL.
- C. Serum potassium of 6.2 mEq/L.
- D. Blood urea nitrogen of 30 mg/dL.
- E. Hemoglobin of 10.5 g/dL.
Correct Answer: B
Rationale: A serum potassium of 6.2 mEq/L indicates hyperkalemia, a life-threatening condition in renal failure due to impaired excretion, risking cardiac arrhythmias. Elevated creatinine, BUN, and low hemoglobin are expected but less urgent.
A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note
- A. High protein
- B. Clear color
- C. Elevated red blood cell count
- D. Increased glucose
Correct Answer: A
Rationale: High protein. A positive CSF for meningitis would include presence of protein, a positive blood culture, decreased glucose, cloudy color with an increased opening pressure, and an elevated white blood cell count.
The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
- A. Pointing out inconsistencies in speech patterns to correct thought disorders
- B. Accepting client and the client's behavior unconditionally
- C. Encouraging dependency in order to develop ego controls
- D. Consistent limit-setting enforced 24 hours per day
Correct Answer: D
Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.
A 12-year-old child is receiving intravenous theophylline (Aminophylline). The child presents with signs of tachycardia and irritability.
Which of the following nursing actions is MOST appropriate?
- A. Decrease external stimuli in the child's room.
- B. Administer an analgesic as ordered.
- C. Notify and advise the physician of the child's status.
- D. Document the assessments and continue to observe.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may help the client to cope with current symptoms, but is not highest priority (2) will mask the signs of toxicity (3) correct-signs of toxicity need to be reported to the physician (4) does not take action to resolve the problem