Nokea
Which of the following is a risk factor for toxic shock syndrome (TSS)?
- A. Changing tampons every 3 hours.
- B. Avoiding use of deodorized tampons.
- C. Alternating tampons with sanitary pads.
- D. Using only tampons at night.
Correct Answer: D
Rationale: Using tampons only at night increases TSS risk due to prolonged use, allowing bacterial growth. Frequent changing and alternating with pads reduce risk.
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The nurse is caring for a client with a history of venous insufficiency who is prescribed horse chestnut extract. The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild nausea.
- B. Bleeding.
- C. Headache.
- D. Fatigue.
Correct Answer: B
Rationale: Horse chestnut extract may increase bleeding risk, so bleeding should be reported immediately.
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
- A. Remove the inner cannula every 2 hours for cleaning.
- B. Secure the tracheostomy ties with a square knot.
- C. Use cut gauze under the neck plate to protect the skin.
- D. Suction the inner cannula on completion of the procedure.
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
The physician is calling in an order for ampicillin for a neonate. The nurse should do which of the following? Select all that apply.
- A. Write down the order.
- B. Ask the physician to come to the hospital and write the order on the chart.
- C. Repeat the order to the physician over the telephone.
- D. Ask the physician to confirm that the order is correct.
- E. Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse.
Correct Answer: A,C,D
Rationale: Writing the order, repeating it back, and confirming with the physician ensure accuracy and safety for a telephone order.
After surgery to create a urinary diversion, the client is at risk for a urinary tract infection. The nurse should plan to incorporate which of the following interventions into the client's care?
- A. Clamp the urinary appliance at night.
- B. Empty the urinary appliance when one-third full.
- C. Administer prophylactic antibiotics.
- D. Change the urinary appliance daily.
Correct Answer: B
Rationale: Emptying the appliance when one-third full prevents urine stasis, reducing infection risk.
The nurse is giving care to an infant in an oxygen hood (see figure). The nurse should do which of the following. Select all that apply.
- A. Assure that the oxygen is not blowing directly on the infant’s face.
- B. Place the butterfl y mobile on the outside of the hood.
- C. Immobilize the infant with restraints.
- D. Remove the hood for 10 minutes every hour.
- E. Encourage the parents to visit the child.
Correct Answer: A,B,E
Rationale: When an oxygen hood is used, the nurse should be sure the oxygen source is not directed on the infant’s face to avoid skin irritation. Mobiles can be used to provide visual stimulation, but they should not be placed inside of the hood where they are a potential choking hazard. It is not necessary to restrain the infant unless there is an indication to do so, and the physician has written the order. There should be as little movement in and out of the hood as possible in order to maintain the warm and humid oxygen levels. The nurse should encourage the parents to visit the child and provide verbal and tactile stimulation.