Nokea
When educating an adolescent diagnosed with bacterial conjunctivitis about how to prevent the spread of their infection, which of the following points should you include?
- A. Do not share towels or washcloths with family members.
- B. Stay home from school until they have taken antibiotics for 48 hours.
- C. Apply a warm compress to lessen any irritation.
- D. Throw out the contact lenses and get new ones.
- E. Perform hand hygiene, especially prior to touching face or eyes
Correct Answer: A, D, E
Rationale: Not sharing towels, discarding contact lenses, and hand hygiene prevent the spread of bacterial conjunctivitis. Warm compresses are not recommended, and 24 hours of antibiotics is typically sufficient for returning to school.
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The nurse assesses the new stoma of a client diagnosed with Crohn's disease. Which of these assessment findings will alert the nurse that the stoma has retracted?
- A. Narrowed and flattened
- B. Concave and bowl-shaped
- C. Dry and reddish-purple
- D. Pinkish-red and moist
Correct Answer: B
Rationale: A retracted stoma appears concave and bowl-shaped, indicating it has pulled below the skin surface.
A nurse is taking care of a client with acute peritonitis. The nurse should do which of the following to meet the client's nutritional needs?
- A. administer feedings via nasogastric (NG) tube
- B. administer gastric enteral feedings
- C. feed the client orally
- D. administer parenteral nutrition
Correct Answer: D
Rationale: Acute peritonitis often requires bowel rest due to inflammation, making oral or enteral feedings inappropriate. Parenteral nutrition is indicated to meet nutritional needs.
The nurse is caring for a client who has been prescribed sertraline. The nurse understands that this medication is prescribed for which of the following conditions?
- A. Major Depressive Disorder
- B. Attention Deficit Hyperactivity Disorder
- C. Obsessive-Compulsive Disorder
- D. Generalized Anxiety Disorder
- E. Bipolar Disorder
Correct Answer: A, C, D
Rationale: Sertraline, an SSRI, is indicated for Major Depressive Disorder, Obsessive-Compulsive Disorder, and Generalized Anxiety Disorder, but not for ADHD or Bipolar Disorder.
While preparing to change the dressing of a female patient with end-stage renal disease, the nurse notices that the patient's son is silently holding her hand and praying. Which of the following should be the nurse's initial action?
- A. Continue preparing for the procedure in the room.
- B. Notify the chaplain.
- C. Leave the room quietly and come back after 15 minutes to change the client's dressing.
- D. Ask the son if he wants the nurse to join in prayer.
Correct Answer: C
Rationale: Respecting the spiritual moment, leaving the room quietly allows privacy and maintains dignity.
The following scenario applies to the next 1 items
The nurse is caring for a 72-year-old client in the emergency department (ED)
Item 1 of 1
Nurses' Notes
1430: 72-year-old male was brought to the ED with reports of dyspnea, chest pain, diaphoresis, and restlessness. The client's daughter reports that he recently took a long drive across several states and that the symptoms started abruptly. The client's oxygen saturation was 80% on room air and improved to 86% on 100% FiO2 via a nonrebreather mask. The physician was immediately notified at this time of the client's condition and came to the bedside for evaluation.
1442: The physician ordered rapid sequence intubation medications for immediate endotracheal intubation (ETT). The physician intubated the client using a #8 ETT and connected the client to mechanical ventilation using assist-control at a tidal volume of 500 mL, rate of 12/minute, 100% FiO2, PEEP 5 cm H2O. Post-intubation vital signs: T 99° F (37° C), P110, RR 12, BP 90/62, pulse oximetry reading 98%.
The nurse has reviewed both of the Nurses' Note entries and is planning care for the client. For each potential nursing intervention, click to specify whether the intervention is indicated or contraindicated for the care of the client.
- A. Request an order for a chest radiograph (x-ray)
- B. Obtain an order for an arterial blood gas (ABG)
- C. Collaborate with respiratory therapy to assist in the client's care
- D. Place the client in low-Fowler's position
- E. Request an order to administer an 0.45% saline intravenous fluid bolus
- F. Turn the client every four hours
- G. Suction the endotracheal tube (ETT) every two hours
Correct Answer: A, B, C, F (indicated); D, E, G (contraindicated)
Rationale: Indicated: Chest x-ray confirms tube placement, ABG assesses ventilation, respiratory therapy collaboration optimizes care, and turning prevents complications. Contraindicated: Low-Fowler€™s position worsens respiratory distress, 0.45% saline is inadequate for hypovolemia, and routine ETT suctioning is unnecessary.