Nokea
The school nurse assessed and referred a 14-year-old with scoliosis. An 18° curvature of the spine was diagnosed. Which treatment plan would the nurse expect?
- A. Application of a Milwaukee brace
- B. Electrical stimulation to the outward side of the curve
- C. Re-evaluation, with no treatment at this time
- D. Surgical realignment of the spine
Correct Answer: C
Rationale: An 18° scoliosis curvature is mild and typically monitored with re-evaluation, as bracing or surgery is reserved for curvatures >25° or >40°, respectively.
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A client with angina is being discharged with a prescription for Transderm Nitro (nitroglycerin) patches. The nurse should tell the client to:
- A. Shave the area before applying the patch
- B. Remove the old patch and clean the skin with alcohol
- C. Cover the patch with plastic wrap and tape it in place
- D. Avoid cutting the patch because it will alter the dose
Correct Answer: B
Rationale: Removing the old patch and cleaning the skin with alcohol ensures proper adhesion and prevents irritation or overdose from residual medication.
The nurse is caring for a client admitted with chest pain and atrial fibrillation. The nurse accidentally gives the client the wrong dose of digoxin. The client is monitored throughout the shift and no ill effects are noted. Which actions by the nurse are correct? Select all that apply.
- A. fill out an incident report and make a note of it in the nurse's notes
- B. print out rhythm strips every 2 hours and place on the client's chart
- C. fill out an incident report and notify the health care provider for further orders
- D. notify the health care provider at the end of the shift, since no ill effects were observed
- E. notify the pharmacy that they loaded the wrong dose in the automatic medication dispensing system
Correct Answer: C
Rationale: Filling out an incident report and notifying the provider immediately are necessary to address the medication error and ensure client safety, even if no ill effects were observed.
Which observation in the newborn of a diabetic mother would require immediate nursing intervention?
- A. Crying
- B. Wakefulness
- C. Jitteriness
- D. Yawning
Correct Answer: C
Rationale: Jitteriness in a newborn of a diabetic mother may indicate hypoglycemia, which requires immediate nursing intervention to prevent complications.
A 15-year-old client was involved in an auto accident and requires emergency surgery to control bleeding, but both parents are out of town and unable to sign the consent form. Which of the following is the most appropriate action?
- A. The client signs the consent form.
- B. The parents give telephone consent with two witnesses listening.
- C. The parents give email consent.
- D. The physician operates without consent because of the emergency situation.
Correct Answer: D
Rationale: In an emergency where a minor requires life-saving surgery and parents are unavailable, the physician can proceed without consent (D) to save the client's life. Client consent (A), telephone consent (B), or email consent (C) are not appropriate in this urgent situation.
All of the following are common symptoms seen in clients diagnosed with tuberculosis (TB) EXCEPT
- A. nail clubbing.
- B. night sweats.
- C. weight gain.
- D. fever.
Correct Answer: C
Rationale: TB symptoms include night sweats, fever, and weight loss. Weight gain is not typical, and nail clubbing is more associated with chronic lung conditions like COPD.