Nokea
Which activity is suitable for a client who suffered an uncomplicated myocardial infarction (MI) 2 days ago?
- A. Sitting in the bedside chair for 15 minutes three times a day
- B. Remaining on strict bed rest with bedside commode privileges
- C. Ambulating in the room and hall as tolerated
- D. Sitting on the bedside for 5 minutes three times a day with assistance
Correct Answer: A
Rationale: Sitting in a chair for short periods is appropriate 2 days post-MI to promote circulation and prevent complications, while ambulation is too strenuous.
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When caring for the child with autistic disorder, the nurse should:
- A. Take the child to the playroom to be with peers
- B. Assign a consistent caregiver
- C. Place the child in a ward with other children
- D. Assign several staff members to provide care
Correct Answer: B
Rationale: A consistent caregiver provides stability and reduces anxiety in a child with autism.
The nurse assesses a client complaining of a headache. When the nurse shines a light on the frontal and maxillary sinuses, the light does not penetrate the tissues. What is the best interpretation of this finding?
- A. This is a normal finding indicating no problem in the sinuses.
- B. Inflammation is present in the sinuses.
- C. The cavity likely contains fluid or pus.
- D. The client has a sinus infection.
Correct Answer: C
Rationale: Lack of light penetration during transillumination suggests fluid or pus in the sinuses, indicating a potential infection or obstruction.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. High fever
- B. Nonproductive cough
- C. Rhinitis
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: High fever is a hallmark of bacterial pneumonia due to the body's response to infection.
The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:
- A. Within 72 hours of delivery
- B. Within 1 week of delivery
- C. Within 2 weeks of delivery
- D. Within 1 month of delivery
Correct Answer: A
Rationale: RhoGam must be administered within 72 hours postpartum to prevent Rh sensitization.
The nurse caring for the child with a large meningomylocele is aware that the priority care for this client is to:
- A. Cover the defect with a moist, sterile saline gauze
- B. Place the infant in a supine position
- C. Feed the infant slowly
- D. Measure the intake and output
Correct Answer: A
Rationale: Moist, sterile gauze prevents infection and drying of the meningomyelocele defect.