Nokea
The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child's back. Which statement by the parents indicates that they understand this procedure?
- A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
- B. To prevent infection, the dressing should be kept dry to avoid excess moisture
- C. The skin incision should be kept moist to promote healing and prevent dryness
- D. The incision should be protected from fecal contamination by an intact dressing
Correct Answer: D
Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.
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Prior to surgery, written consent must be obtained. What is the nurse's legal responsibility with regard to obtaining written consent?
- A. Validate the client's understanding of the surgical procedure to be conducted
- B. Explain the surgical procedure to the client and ensure the client comprehends before signing the consent form
- C. Ensure the client, not a family member, signs the surgical consent form
- D. Confirm that the surgical consent form is signed and included in the client's record
Correct Answer: A
Rationale: The nurse's legal responsibility in obtaining written consent is to validate the client's understanding of the surgical procedure to be conducted. This process ensures that the client has been comprehensively informed about the procedure, including its risks, benefits, and alternatives. Choice B is incorrect because it does not emphasize the validation of client understanding, which is crucial for informed consent. Choice C is incorrect as the client, not a family member, should provide consent unless specific circumstances dictate otherwise. Choice D is incorrect because although ensuring the consent form is signed and filed is important, it does not address the primary responsibility of confirming the client's comprehension and ensuring informed consent.
A continuous infusion of nitroglycerin is prescribed for an adult male admitted with an acute myocardial infarction. The client is experiencing active chest pain that he describes as 8 out of 10. Which intervention is most important for the nurse to implement?
- A. Administer the infusion via an infusion pump
- B. Obtain the current serum potassium level
- C. Continuously monitor blood pressure
- D. Teach guided imagery to decrease pain
Correct Answer: C
Rationale: Continuously monitoring blood pressure is crucial in this case because nitroglycerin can cause hypotension as a side effect. Monitoring blood pressure allows the nurse to assess the client's response to the medication and detect any signs of hypotension promptly. This intervention is essential to ensure the effectiveness of nitroglycerin therapy and prevent potential complications. Administering the infusion via an infusion pump is important for accurate dosing but not the most critical at this moment. Obtaining the current serum potassium level is important but not the most immediate concern when the client is experiencing active chest pain. Teaching guided imagery may be beneficial for pain management, but in this scenario, monitoring blood pressure takes precedence due to the potential side effects of nitroglycerin.
After a sudden loss of consciousness, a female client is taken to the ED, and initial assessment indicates that her blood glucose level is critically low. Once her glucose level is stabilized, the client reports that she was recently diagnosed with anorexia nervosa and is being treated at an outpatient clinic. Which intervention is more important to include in this client's discharge plan?
- A. Describe the importance of maintaining stable blood glucose levels.
- B. Encourage a balanced and nutritious diet.
- C. Reinforce the need to continue outpatient treatment.
- D. Educate on the risks of untreated anorexia nervosa.
Correct Answer: C
Rationale: Continuing outpatient treatment is crucial for managing anorexia nervosa and preventing future complications. Reinforcing the need to continue outpatient treatment ensures ongoing support, monitoring, and therapy for the client's anorexia nervosa. Describing the importance of maintaining stable blood glucose levels (Choice A) is relevant but does not address the underlying eating disorder directly. Encouraging a balanced and nutritious diet (Choice B) is important; however, specific dietary recommendations should be tailored to the individual's condition by healthcare providers. Educating on the risks of untreated anorexia nervosa (Choice D) is informative but does not provide a direct actionable step for the client's immediate discharge plan, unlike the importance of continuing outpatient treatment.
The public health nurse received funding to initiate a primary prevention program in the community. Which program best fits the nurse's proposal?
- A. Case management and screening for clients with HIV.
- B. Regional relocation center for earthquake victims.
- C. Vitamin supplements for high-risk pregnant women.
- D. Lead screening for children in low-income housing.
Correct Answer: C
Rationale: The correct answer is C: Vitamin supplements for high-risk pregnant women. This option aligns with primary prevention by preventing deficiencies before they occur, which is a key aspect of primary prevention. Providing vitamin supplements to high-risk pregnant women can help prevent birth defects and complications. Choices A, B, and D do not align with primary prevention strategies. Case management and screening for clients with HIV (Choice A) is more of a secondary prevention strategy aimed at early detection and management. A regional relocation center for earthquake victims (Choice B) is focused on addressing the aftermath of a disaster rather than preventing it. Lead screening for children in low-income housing (Choice D) is more about early detection and intervention rather than primary prevention.
While a patient is receiving beta-1b interferon every other day for multiple sclerosis, which serum laboratory test findings should the nurse monitor to assess for possible bone marrow suppression caused by the medication? (Select all that apply)
- A. Platelet count
- B. White blood cell count (WBC)
- C. Sodium and potassium
- D. Red blood cell count (RBC)
Correct Answer: A
Rationale: Beta-1b interferon can lead to bone marrow suppression, impacting blood cell production. Therefore, monitoring the platelet count, white blood cell count (WBC), and red blood cell count (RBC) is essential. Platelet count is a direct indicator of bone marrow function and can show early signs of bone marrow suppression. While sodium, potassium, and albumin/protein levels are important for overall health assessment, they are not directly associated with bone marrow suppression caused by the medication.