Nokea
The nurse reinforces teaching for the parents of a child with impetigo. Which of the following statements by a parent indicates correct understanding of teaching? Select all that apply.
- A. I should wash my hands before and after touching the infected area.
- B. I will clean the infected area with alcohol before applying the antibiotic ointment.
- C. I will separate my child's clothing from other laundry and wash them with hot water.
- D. My child's fingernails should be kept short and well-filed.
- E. The infection could easily spread to other children who come in contact with my child.
Correct Answer: A,C,D,E
Rationale: Hand hygiene, separating laundry, keeping nails short, and recognizing the contagious nature of impetigo are correct. Cleaning with alcohol is inappropriate as it may irritate the skin.
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The nurse monitoring a newborn after birth observes a bluish discoloration of the hands and feet. The trunk is pink. What is the nurse's initial action?
- A. Apply blow-by oxygen and count respirations
- B. Auscultate heart tones for a murmur
- C. Observe for expiratory grunting
- D. Place infant skin-to-skin with mother
Correct Answer: D
Rationale: Acrocyanosis is normal in newborns. Skin-to-skin contact promotes thermoregulation and bonding.
The nurse is observing a client who had a left total knee replacement using a cane to descend stairs. It would demonstrate correct technique if the client descends the stairs by placing the
- A. cane on the step first, followed by the affected leg, and then the unaffected leg
- B. cane on the step first, followed by the unaffected leg, and then the affected leg
- C. affected leg on the step first, followed by the cane, and then the unaffected leg
- D. unaffected leg on the step first, followed by the affected leg, and then the cane
Correct Answer: A
Rationale: For descending stairs, the cane and affected leg move together after the unaffected leg, providing stability.
The doctor has ordered 1 mg of Stadol (butorphanol) to be given IM. The medication is available in 4 mg per mL. The nurse should administer:
- A. 0.5 mL
- B. 0.25 mL
- C. 0.75 mL
- D. 1.0 mL
Correct Answer: B
Rationale: Calculate: 1 mg ÷ 4 mg/mL = 0.25 mL. This ensures the correct dose of Stadol is administered.
A hearing-impaired client is becoming withdrawn and depressed. He reports that even with a hearing aid, he is having increased difficulty hearing. Which suggestion is least likely to be helpful?
- A. Get a hearing guide dog.
- B. Join a social club.
- C. Get a telephone TDD.
- D. Get a closed-caption TV.
Correct Answer: A
Rationale: A hearing guide dog is less helpful for communication compared to social engagement, TDD, or closed-caption TV, which directly address hearing loss.
The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation