Nokea
Which is most important for the nurse to include in the child's plan of care for a child with spina bifida (myelodysplasia)?
- A. Avoid the child's exposure to latex.
- B. Do intermittent urinary catheterization.
- C. Provide dietary fiber supplements daily.
- D. Complete a referral for physical therapy.
Correct Answer: A
Rationale: Avoiding latex exposure is critical due to the high risk of latex allergy in children with spina bifida.
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The client is three (3) hours postoperative left AKA. The client tells the nurse, 'My left foot is killing me. Please do something.' Which intervention should the nurse implement?
- A. Explain to the client his left leg has been amputated.
- B. Medicate the client with a narcotic analgesic immediately.
- C. Instruct the client on how to perform biofeedback exercises.
- D. Place the client's residual limb in the dependent position.
Correct Answer: B
Rationale: Phantom limb pain is treated with analgesics; narcotics provide immediate relief. Explaining the amputation dismisses pain, biofeedback is long-term, and dependent positioning is inappropriate.
The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign?
- A. Dyspnea
- B. Chest pain
- C. Delirium
- D. Petechiae
Correct Answer: D
Rationale: D. The nurse should assess for petechiae. Petechiae (small purplish hemorrhagic spots on the skin) are thought to be due to transient thrombocytopenia. They can occur over the chest, anterior axillary folds, hard palate, buccal membranes, and conjunctival sacs.
A femoral head replacement was performed on an elderly client. Postoperatively, the nurse positions the client with an abductor pillow between the client's legs. What is the primary reason for this?
- A. This position will promote greater comfort.
- B. Abduction promotes greater circulation to the hip joint.
- C. Abduction will prevent the prosthesis from snapping out of the socket.
- D. This position will help to prevent pressure on the sciatic nerve.
Correct Answer: C
Rationale: An abductor pillow maintains abduction, preventing prosthesis dislocation post-femoral head replacement.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate therapy?
- A. Constipation
- B. Dry mouth
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores are a common side effect of methotrexate due to its effect on mucosal cells.
Which staff nurse should the charge nurse assign to the client recovering from a repair of the hallux valgus?
- A. A new graduate nurse.
- B. An experienced nurse.
- C. A nurse practitioner.
- D. An unlicensed assistive personnel.
Correct Answer: B
Rationale: An experienced nurse is best suited for postoperative hallux valgus care, requiring skilled assessment. New graduates lack experience, NPs focus on advanced care, and UAPs cannot assess.