Nokea
Which nursing instruction concerning ice applications is appropriate to give the parents of a 12-year-old child with a sprained ankle?
- A. Ice can be applied and left on until the swelling is gone.
- B. Ice can be applied but must be removed every 30 minutes to 1 hour to check the ankle.
- C. Ice should not be used for treating sprains; heat should be used instead.
- D. There is no danger associated with the application of ice.
Correct Answer: B
Rationale: Ice should be applied intermittently (e.g., 20-30 minutes on, then off) to prevent tissue damage and allow skin assessment, making removal every 30 minutes to 1 hour appropriate.
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The nurse is caring for the client who has just given birth to a baby boy. The mother is O negative. The nurse should assess for ABO incompatibility and hyperbilirubinemia if the infant’s blood type is which type?
- A. O positive
- B. O negative
- C. A negative
- D. Any type
Correct Answer: C
Rationale: ABO incompatibility occurs when a mother with type O blood (no antigens A/B antibodies) has an infant with A or B blood (e.g. A negative) leading to hemolysis and hyperbilirubinemia. O blood types are compatible.
Which of the following is a priority for the nurse to assess when testing the child's urine?
- A. Blood in the urine
- B. Bilirubin in the urine
- C. Ketones in the urine
- D. White blood cells in the urine
Correct Answer: C
Rationale: In DKA, assessing for ketones in the urine is a priority, as ketonuria confirms the presence of ketones, a hallmark of DKA resulting from fat metabolism due to insulin deficiency.
The nurse is caring for the infant in the neonatal ICU who has an umbilical artery catheter (UAC) in place. To monitor for and prevent complications with this catheter,which actions should be planned by the nurse? Select all that apply.
- A. Check the position marking on the catheter every shift.
- B. Position the tubing close to the infant’s lower limbs.
- C. Check for erythema or discoloration of the abdominal wall.
- D. Palpate for femoral,pedal,and tibial pulses every 2 to 4 hours.
- E. Reposition the catheter tubing every hour.
- F. Monitor blood glucose levels.
Correct Answer: A,C,D,F
Rationale: Check catheter position abdominal wall pulses every 2–4 hours and glucose levels to monitor for displacement bleeding perfusion issues or hypoglycemia. Keep tubing away from limbs and avoid frequent repositioning to reduce infection risk.
The nurse is admitting a neonate after delivery who is diagnosed with a myelomeningocele. Which intervention should the nurse implement immediately?
- A. Positions the infant prone and covers the sac with sterile gauze.
- B. Notifies the surgeon on call that the infant is ready for surgery.
- C. Applies a pressure dressing to the sac and starts an intravenous access.
- D. Positions the infant prone,hips slightly flexed and legs abducted.
Correct Answer: D
Rationale: Positioning prone with hips flexed and legs abducted minimizes sac tension and rupture risk. Sterile gauze risks adherence surgery follows stabilization and pressure dressings risk rupture.
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.