Nokea
When is the best time to collect urine specimen for routine urinalysis and C/S?
- A. Early morning
- B. Later afternoon
- C. Midnight
- D. Before breakfast
Correct Answer: A
Rationale: Early morning urine first void e.g., concentrated is best for urinalysis/C&S, detecting glucose, bacteria. Later dilutes; midnight, pre-breakfast vary. Nurses collect e.g., 6 AM for accuracy, per protocols.
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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 is normal (36.6-38°C) e.g., high-normal from cough stress. Not high (>38°C), low (<36.6°C), or low-end. Nurses interpret this e.g., monitor trends in acute cases, per standard ranges.
A 5-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel is a key sign of bacterial meningitis in a 5-month-old, indicating increased intracranial pressure from infection, alongside fever, irritability, and seizures. Periorbital edema isn't typical, a positive Babinski is normal at this age, and a negative scarf sign relates to tone, not pressure. Nurses assess this bulging fontanel urgently, as it signals worsening inflammation, guiding immediate antibiotic and supportive care to prevent brain damage or death in this critical condition.
Which of the following is the nurse's role in the health promotion
- A. Health risk appraisal
- B. Teach client to be effective health consumer
- C. Worksite wellness
- D. None of the above
Correct Answer: B
Rationale: Teaching clients to manage their health effectively is a key nursing role in promotion.
A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?
- A. Avoid beverages containing caffeine
- B. Take a sleep medication regularly at bedtime
- C. Watch television for 30 minutes in bed to relax before falling asleep
- D. Advise the client to take several naps during the day
Correct Answer: A
Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.
Miss Imelda asked you, What is WET TO DRY Dressing method? Your best response is
- A. It is a type of mechanical debridement using Wet dressing that is applied and left to dry to remove dead tissues
- B. It is a type of surgical debridement with the use of Wet dressing to remove the necrotic tissues
- C. It is a type of dressing where in, The wound is covered with Wet or Dry dressing to prevent contamination
- D. It is a type of dressing where in, A cellophane or plastic is placed on the wound over a wet dressing to stimulate healing of the wound in a wet medium
Correct Answer: A
Rationale: The wet-to-dry dressing method (A) is a mechanical debridement technique where a wet gauze is applied to a wound, then dries, adhering to and removing necrotic tissue when peeled off. Surgical debridement (B) involves cutting, not dressings. Option C misrepresents it as a protective dressing, ignoring debridement. Option D describes wet-to-moist dressings, not wet-to-dry. Wet-to-dry targets dead tissue removal, aiding healing in wounds like Imelda's, making A accurate and the best response.