Nokea
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- A. Tire easily
- B. Grow normally
- C. Need more calories
- D. Be more susceptible to viral infections
Correct Answer: A
Rationale: A ventricular septal defect causes increased pulmonary blood flow, leading to easy tiring due to cardiac workload.
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The nurse is assisting in the assessment of the patient admitted with 'extreme abdominal pain.' The nurse asks the client about the medication that he has been taking because:
- A. Interactions between medications will cause abdominal pain.
- B. Various medications taken by mouth can affect the alimentary tract.
- C. This will provide an opportunity to educate the patient regarding the medications used.
- D. The types of medications might be attributable to an abdominal pathology not already identified.
Correct Answer: D
Rationale: Medications can cause or exacerbate abdominal pathology, making it essential to assess their role in the patient's symptoms.
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
- A. reduce fluid intake to 1,500 ml/day
- B. take a warm shower twice a day
- C. apply a tight binder around her breasts
- D. come in to see the physician immediately as this is abnormal
Correct Answer: C
Rationale: A tight binder helps relieve breast engorgement by suppressing lactation in bottle-feeding mothers, a normal postpartum occurrence.
The primary reason for rapid continuous rewarming of the area affected by frostbite is to:
- A. Lessen the amount of cellular damage
- B. Prevent the formation of blisters
- C. Promote movement
- D. Prevent pain and discomfort
Correct Answer: A
Rationale: Rapid rewarming minimizes cellular damage by restoring blood flow and preventing further tissue injury in frostbite.
A client with a fractured hip is being taught correct use of the walker. The nurse is aware that the correct use of the walker is achieved if the:
- A. Palms rest lightly on the handles
- B. Elbows are flexed 0°
- C. Client walks to the front of the walker
- D. Client carries the walker
Correct Answer: A
Rationale: Palms resting lightly on the handles ensures proper weight distribution and stability.
The nurse is teaching a client with a new diagnosis of glaucoma about eye drop administration. Which of the following instructions should the nurse include?
- A. Apply pressure to the inner canthus after instilling drops.
- B. Instill the drops directly onto the cornea.
- C. Shake the bottle vigorously before use.
- D. Store the drops in the refrigerator.
Correct Answer: A
Rationale: applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of the medication