Nokea
Which instruction should be given to a client taking Lugol's solution prior to a thyroidectomy?
- A. Take at bedtime.
- B. Take the medication with juice.
- C. Report changes in appetite.
- D. Avoid the sunshine while taking the medication.
Correct Answer: B
Rationale: Lugol's solution (iodine) should be taken with juice to mask its taste and reduce gastric irritation. Taking it at bedtime , reporting appetite changes , or avoiding sunshine are not specific to this medication.
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A 6-year-old child is receiving chemotherapy for leukemia. Which comment by the child indicates to the nurse that the child is adjusting well to the therapy?
- A. I am so tired. I want Mommy to hold me.'
- B. Look at my new hat. I wear it all the time. It's pretty.'
- C. See all my bruises. They are funny colors.'
- D. I wish I could eat pizza, but everything makes me throw up.'
Correct Answer: B
Rationale: Wearing a hat proudly suggests positive coping with hair loss from chemotherapy, indicating adjustment, unlike complaints of fatigue, bruising, or nausea.
The nurse is reinforcing discharge teaching with the parent of a 6-year-old client who had a tonsillectomy 4 hours ago. The nurse should reinforce that it would be a priority to notify the health care provider if the client experiences
- A. Ear pain
- B. Foul-smelling breath
- C. Frequent swallowing
- D. Low-grade fever
Correct Answer: C
Rationale: Frequent swallowing (C) may indicate bleeding, a serious post-tonsillectomy complication requiring immediate reporting. Ear pain (A), bad breath (B), and low-grade fever (D) are common and less urgent.
The nurse enters the room of a client who had major abdominal surgery 1 week ago and notes dehiscence and evisceration of the surgical incision. The nurse should immediately place the client in the
- A. Low Fowler position with the knees bent
- B. Prone position
- C. Supine position with the head of the bed flat
- D. Side-lying position
Correct Answer: A
Rationale: Low Fowler with knees bent (A) reduces abdominal tension, preventing further evisceration while awaiting surgical intervention. Prone (B), supine flat (C), or side-lying (D) increase strain or risk organ protrusion.
The nurse is caring for a 9-year-old client with cystic fibrosis who is scheduled to receive pancrelipase at 1200. The client states, 'I am not hungry now. I want to eat lunch in a few hours.' Which of the following actions should the nurse take?
- A. Omit the dose of medication.
- B. Administer half the dose of medication.
- C. Administer the dose of medication with a small snack
- D. Hold the dose of medication until the client is ready to eat.
Correct Answer: C
Rationale: Pancrelipase aids digestion in cystic fibrosis and should be taken with food. A small snack (C) ensures enzyme effectiveness while respecting the child’s appetite. Omitting (A) or halving (B) the dose risks malabsorption, and holding (D) delays nutrition.
Which situations require that the nurse report to an appropriate authority? Select all that apply.
- A. Client has a row of 3-inch circles down the back from 'cupping'
- B. Client is diagnosed with gonorrhea and requests not to report under the Health Insurance Portability and Accountability Act (HIPAA)
- C. RN thinks a teenage client’s signs are from abuse, but the health care provider does not
- D. RN thinks an elderly client’s signs are from abuse but the client denies this
- E. Syphilis is diagnosed in an 11-year-old who denies sexual activity
Correct Answer: B,C,D,E
Rationale: Gonorrhea (B) and syphilis (E) are reportable diseases, regardless of HIPAA. Suspected abuse in a teenager (C) or elderly client (D) mandates reporting, despite provider or client denial. Cupping (A) is a cultural practice, not abuse.