Nokea
Tympanic temperature is taken from John, A client who was brought recently into the ER due to frequent barking cough. The temperature reads 37.9 Degrees Celsius. As a nurse, you conclude that this temperature is
- A. High
- B. Low
- C. At the low end of the normal range
- D. At the high end of the normal range
Correct Answer: D
Rationale: Tympanic temp of 37.9°C falls within normal (36.6-38°C) e.g., slightly elevated from barking cough stress. It's not high (>38°C), low (<36.6°C), or low-end. Nurses interpret this as high-normal, monitoring for trends in acute respiratory cases, per standard ranges.
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When teaching a client with a new diagnosis of heart failure about dietary management, which of the following statements should the nurse include?
- A. Increase your intake of sodium-rich foods.
- B. Decrease your intake of sodium-rich foods.
- C. Avoid foods that contain lactose.
- D. Increase your intake of dairy products.
Correct Answer: B
Rationale: The correct answer is to decrease the intake of sodium-rich foods. Sodium restriction is crucial in managing heart failure as it helps to reduce fluid retention and alleviate symptoms. Excessive sodium intake can lead to fluid buildup in the body, worsening heart failure. Therefore, advising the client to decrease sodium-rich foods is essential for their overall health and management of the condition. Choices A, C, and D are incorrect. Increasing intake of sodium-rich foods (Choice A) would worsen fluid retention and heart failure symptoms. Avoiding foods that contain lactose (Choice C) is not directly related to heart failure management through sodium restriction. Increasing intake of dairy products (Choice D) may not be suitable for all heart failure patients, especially if they need to limit saturated fats or cholesterol in their diet.
The nurse chose to respect Mr. Gary's refusal of care. This is an example of?
- A. Ethics
- B. Health promotion
- C. Care coordination
- D. Nursing informatics
Correct Answer: A
Rationale: Respecting care refusal is ethics (A) moral decision, per principles (autonomy). Promotion (B) prevents, coordination (C) organizes, informatics (D) tech not ethics-specific. A fits moral choice, making it correct.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Correct Answer: D
Rationale: Sulfamylon cream causes a burning sensation on application to burns, a known effect due to its penetration into damaged tissue, requiring pain management a pediatric care priority. Staining, cooling, or thyroid impact aren't typical. Nurses prepare for this, using analgesics to ease discomfort, supporting healing in young clients.
The nurse is caring for a client following a TURP. The client's catheter becomes obstructed. The nurse should:
- A. Notify the physician immediately
- B. Increase the flow rate of the irrigating solution
- C. Milk the catheter to remove the obstruction
- D. Remove the catheter and replace it with a new one
Correct Answer: A
Rationale: Notifying the physician immediately for an obstructed catheter post-TURP prevents bladder distention or bleeding increasing flow risks pressure, milking may dislodge clots unsafely, and removal isn't nurse-initiated. Nurses act fast, ensuring patency, critical in urologic surgery.
Mr. Gary's wife wanted to see the body before it is removed from the room. Which of the following is the most appropriate response by the nurse?
- A. I'm sorry but you can't see him now'
- B. Let me prepare the body first then you can see him'
- C. It's better if you don't see him'
- D. You can see him but only for a minute'
Correct Answer: B
Rationale: Let me prepare the body first (B) is most appropriate respects Mrs. Gary's wish while ensuring dignity, per care standards. Denying (A) or discouraging (C) dismisses, time-limiting (D) restricts. B balances support and preparation, making it correct.