Nokea
The nurse reinforces teaching to a parent of a 2-month-old client regarding administration of an oral liquid medication. The nurse knows that the parent understands the teaching when the parent performs which action?
- A. Administers the medication in small amounts at the back of the cheek using a syringe
- B. Allows the client to sip the medication from a cup
- C. Expels the medication from a dropper onto the back of the tongue
- D. Mixes the medication in the infant’s bottle of formula
Correct Answer: A
Rationale: Administering small amounts at the back of the cheek with a syringe ensures safe delivery and reduces choking risk in a 2-month-old. Cups, tongue administration, and mixing with formula are unsafe or ineffective.
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The nurse is caring for a client who performs frequent urinary self-catheterizations. Which of the following client assessments would indicate a potential for a latex allergy? Select all that apply.
- A. History of angioedema with lisinopril
- B. History of epilepsy
- C. Known allergy to avocados and bananas
- D. Known allergy to shellfish
- E. Lip swelling when blowing up balloons
Correct Answer: C,E
Rationale: Allergies to avocados, bananas, and latex (balloons) indicate a potential latex allergy due to cross-reactivity. Angioedema with lisinopril, epilepsy, and shellfish allergies are unrelated to latex sensitivity.
A client at 20 weeks gestation reports 'running to the bathroom all the time,' pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client?
- A. Are you having any pain in your lower back or flank area?
- B. Do you wipe from front to back after urinating?
- C. Have you found that you urinate more frequently since becoming pregnant?
- D. Have you had a urinary tract infection in the past?
Correct Answer: A
Rationale: Back or flank pain suggests pyelonephritis, a serious complication of UTI in pregnancy, requiring urgent evaluation. Hygiene, frequency, and history are relevant but less critical than assessing for systemic infection.
A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
- A. Should be packed on ice
- B. Should be kept warm
- C. Should be double bagged
- D. Requires no special handling
Correct Answer: A
Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.
An adult client who had a cervical laminectomy is returned to her room on the nursing care unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. The nurse should position the client in which of the following positions?
- A. Supine
- B. Semi-reclining
- C. Side-lying
- D. Prone
Correct Answer: C
Rationale: Side-lying position promotes comfort and maintains spinal alignment post-cervical laminectomy, reducing strain on the surgical site. Supine or prone positions may increase pressure on the neck, and semi-reclining is less optimal for spinal stability.
The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:
- A. Infection with the tubercle bacillus
- B. Exposure to the tubercle bacillus
- C. Questionable exposure to the tubercle bacillus
- D. No exposure to the tubercle bacillus
Correct Answer: B
Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.