Nokea
The nurse is triaging a child with suspected impetigo. Which action should the nurse take?
- A. Initiate droplet precautions
- B. Set up a decontamination room
- C. Use a disposable blood pressure cuff
- D. Initiate contact precautions
- E. Apply sterile gloves while examining the client
Correct Answer: D, E
Rationale: Impetigo requires contact precautions and sterile gloves to prevent spread during examination.
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The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right
- A. intention
- B. alternative
- C. assessment
- D. task
Correct Answer: D
Rationale: The five rights of delegation include the right task, ensuring appropriate delegation.
The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching?
- A. Egg allergy is a contraindication to giving this vaccine.
- B. This is a three-series vaccine that should be started at birth.
- C. It is safe for breastfeeding women to receive the MMR vaccine.
- D. This vaccine is safe if the client is pregnant.
Correct Answer: C
Rationale: The MMR vaccine is safe for breastfeeding women but contraindicated in pregnancy and not started at birth. Egg allergy is no longer a contraindication.
When assessing a postpartum client, a nurse notes that the client has soaked three perineal pads in the three hours since delivery. The nurse also notes a soft fundus. The initial action for the nurse would be which of the following?
- A. Insert vaginal packing
- B. Massage the client's fundus
- C. Apply an ice pack over the client's perineal area
- D. Administer packed red blood cells
Correct Answer: B
Rationale: A soft fundus and heavy bleeding suggest uterine atony, a common cause of postpartum hemorrhage. Fundal massage is the initial action to stimulate uterine contraction.
The nurse is caring for a client seven hours postoperative following a subtotal thyroidectomy. The client reports peripheral numbness and tingling, muscle twitching, and spasms. The nurse anticipates a prescription for
- A. levothyroxine
- B. hydrocortisone
- C. thiamine
- D. calcium gluconate
Correct Answer: D
Rationale: These symptoms suggest hypocalcemia, a common complication post-thyroidectomy due to parathyroid gland disruption. Calcium gluconate is the appropriate treatment.
The nurse is caring for a client in the second stage of labor. The fetal heart monitor shows late decelerations. The nurse should initially
- A. notify the physician
- B. encourage the client deep-breathe slowly
- C. reposition the client to a left side-lying position
- D. obtain a prescription for intravenous isotonic fluids
Correct Answer: C
Rationale: Repositioning to the left side-lying position improves placental perfusion, addressing late decelerations.