Nokea
Which information regarding the use of aspirin is best for the nurse to discuss with the client?
- A. Aspirin should be discarded if not used within 2 years of first being opened.
- B. Aspirin can cause a slight ringing in the ears that will go away eventually.
- C. If aspirin alone does not help, take one or two ibuprofen (Advil) along with the aspirin.
- D. It is best to take aspirin with food to prevent GI upset.
Correct Answer: D
Rationale: Taking aspirin with food reduces the risk of gastrointestinal upset, a common side effect, making it a key point for safe use.
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Which response by the nurse best explains why insulin must be given subcutaneously?
- A. The oral form of insulin can lead to the worsening of diabetes.
- B. The oral form of insulin is not yet available for use.
- C. Insulin is a protein that is destroyed by digestive enzymes.
- D. Insulin given by the oral route causes severe vomiting.
Correct Answer: C
Rationale: Insulin is a protein hormone that would be broken down by digestive enzymes in the gastrointestinal tract if taken orally, rendering it ineffective. Subcutaneous administration ensures it reaches the bloodstream intact.
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.
Which medication instruction provided by the nurse is most accurate?
- A. Taking your acyclovir as prescribed will prevent the recurrence of lesions.
- B. Your sex partners also need to be treated for 10 days with oral acyclovir.
- C. Use a glove to apply topical acyclovir.
- D. Take the oral acyclovir even when the disease is in remission.
Correct Answer: C
Rationale: Using a glove to apply topical acyclovir prevents self-contamination and virus spread, making it an accurate and safe instruction.
The nurse is completing the 1-minute Apgar assessment on the full-term newborn. The newborn’s HR is 80 bpm. What should the nurse do next?
- A. Assign a 2 for the Apgar score that pertains to the heart rate.
- B. Suction the excess secretions from the newborn’s oral cavity.
- C. Wrap in warm blankets and place on the mother’s abdomen.
- D. Begin immediate positive pressure ventilation on the newborn.
Correct Answer: D
Rationale: A newborn HR of less than 100 bpm scores as a 1 on the HR criterion and indicates a need to begin positive pressure ventilation by bag mask or Neopuff® ventilation. A score of 2 requires HR above 100 bpm. Suctioning is not indicated and wrapping is done after assessment.
The nurse discovers that an African couple from Kenya has not named their 48-hour-old,full-term newborn and the infant and mother are being discharged to home. Which action should the nurse take in response to this information?
- A. Ask the parents to choose a name before discharge.
- B. Encourage other appropriate attachment behaviors.
- C. Document the discharge and that the baby is unnamed.
- D. Delay discharge until parental attachment is addressed.
Correct Answer: C
Rationale: In Kenyan culture naming may occur on the third day with celebration. Documenting the discharge and unnamed status is appropriate; naming isn’t required for attachment.