Nokea
The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room? Select all that apply.
- A. Oral bite prevention device
- B. Oxygen delivery system
- C. Padding on the bed side rails
- D. Soft arm and leg restraints
- E. Suction equipment
Correct Answer: B,C,E
Rationale: Oxygen ensures adequate oxygenation during seizures, padding prevents injury from bed rails, and suction equipment clears airways if secretions accumulate. Oral bite devices are unsafe during seizures due to choking risks, and restraints are not typically used unless absolutely necessary.
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A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?
- A. Increase bladder tone by delaying voiding
- B. When laundering clothing, rinse several times
- C. Use plain water for the bath, shampooing hair last
- D. Have the child use antibacterial soaps while bathing
Correct Answer: C
Rationale: Use plain water for the bath, shampooing hair last. Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTIs in young girls.
The nurse is preparing to perform wound irrigation for a client who sustained a scalp laceration. Which of the following actions should the nurse take?
- A. Hold the syringe 8 in (20.3 cm) above the wound.
- B. Use a 10 mL syringe to draw up the irrigation solution.
- C. Position the client so the irrigation solution flows from the most to least contaminated area.
- D. Flush the wound with low, continuous pressure and dry the surrounding area with sterile gauze.
Correct Answer: C
Rationale: Irrigation should flow from the least to most contaminated area to prevent infection spread. Other options are incorrect techniques.
Clients taking which of the following drugs are at risk for depression?
- A. Steroids
- B. Diuretics
- C. Folic acid
- D. Aspirin
Correct Answer: A
Rationale: Steroids. Corticosteroids can cause depression as a side effect, which may persist even after discontinuation.
The nurse notes that a client with COPD demonstrates increased dyspnea in certain positions. Which position is most likely to lessen the client's dyspnea?
- A. Lying supine with a single pillow
- B. Standing or sitting upright
- C. Side lying with the head elevated
- D. Lying with head slightly lowered
Correct Answer: B
Rationale: The client with chronic obstructive pulmonary disease has increased difficulty breathing when lying down. His respiratory effort is improved by standing or sitting upright or by having the bed in high Fowler's position. Answers A, C, and D do not alleviate the client's dyspnea; therefore they are incorrect.
A client is being discharged with a prescription for apixaban after being treated for a pulmonary embolus. Which clinical data is most concerning to the nurse?
- A. Client eats a vegetarian diet
- B. Client has chronic atrial fibrillation
- C. Client takes indomethacin for osteoarthritis
- D. Client's platelet count is 176,000/mm³ (176 × 10â¹/L)
Correct Answer: C
Rationale: Indomethacin, an NSAID, increases bleeding risk when combined with apixaban, an anticoagulant, making it concerning. The other data are not significant.