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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A 25 years old P2 comes to emergency,after home delivery with heavy bleeding per vaginum. After evaluation and emergency resuscitation she is diagnosed as a case of uterine atony. What is the appropriate medicine in the management of this case:
- A. Oxytocin.
- B. Salbutamol.
- C. Beta blockers.
- D. Magnesium sulphate.
- E. Hydralazine.
Correct Answer: A
Rationale: Oxytocin is the first-line treatment for uterine atony as it stimulates uterine contractions to control postpartum hemorrhage. Other options are not indicated for this condition.
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.
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.
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.
During early postburn care of the child, it is essential for the nurse to closely monitor which of the following?
- A. Unburned skin
- B. Bowel elimination
- C. I.V. fluid therapy
- D. Pupillary response to light
Correct Answer: C
Rationale: I.V. fluid therapy is critical in the early postburn phase to prevent hypovolemic shock and maintain organ perfusion. Close monitoring ensures adequate resuscitation and prevents complications like over- or under-hydration.