Nokea
To reduce the risk of pressure ulcer formation, which of the following activities should the nurse teach the client who is wheelchair-bound as a result of a spinal cord injury?
- A. Bathe daily.
- B. Eat a high-carbohydrate diet.
- C. Shift your weight every 15 minutes.
- D. Move from the bed to the wheelchair every 2 hours.
Correct Answer: C
Rationale: Shifting weight every 15 minutes relieves pressure on bony prominences, reducing pressure ulcer risk. The other options are less directly related to prevention.
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The nurse holds the gauze pledget against an I.M. injection site while removing the needle from the muscle. This technique helps to:
- A. Seal off the track left by the needle in the tissue.
- B. Speed the spread of the medication in the tissue.
- C. Avoid the discomfort of the needle pulling on the skin.
- D. Prevent organisms from entering the body through the skin puncture.
Correct Answer: A
Rationale: Holding gauze against the injection site prevents medication leakage along the needle track, ensuring proper drug absorption.
The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
- A. Give higher doses of pain medication.
- B. Keep patches on the client's eyes to prevent corneal abrasion.
- C. Monitor the temperature of the bathwater.
- D. Avoid turning the client.
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
The nurse is assessing a newborn 12 hours after birth. Which of the following findings should be reported to the physician?
- A. Heart rate of 120 beats per minute.
- B. Respiratory rate of 40 breaths per minute.
- C. Acrocyanosis.
- D. Capillary refill of 5 seconds.
Correct Answer: D
Rationale: Capillary refill of 5 seconds indicates poor perfusion in a newborn, requiring physician notification.
Which oral contraceptive is considered safe for use while breast-feeding because it will not affect the breast milk or breast-feeding?
- A. Estrogen.
- B. Estrogen and progestin.
- C. Progestin.
- D. Testosterone.
Correct Answer: C
Rationale: Progestin-only contraceptives are safe during breast-feeding, as they do not affect milk production.
The mother of a child with newly diagnosed Duchenne's muscular dystrophy asks how her child developed the disease. The nurse formulates a response incorporating which of the following statements about its transmission?
- A. It is an autosomal recessive genetic disorder
- B. It is a genetic disorder carried by males and transmitted to male children
- C. It is a disorder primarily transmitted by males in the family
- D. It is a disorder usually carried by females and transmitted to male children
Correct Answer: D
Rationale: Duchenne's muscular dystrophy is an X-linked recessive disorder, typically carried by females and transmitted to male children, who are more likely to express the disease.