Nokea
Which of the following nursing actions should be the priority for an infant admitted with a positive stool culture for Salmonella?
- A. Change the diet to clear liquids.
- B. Initiate intravenous fluids.
- C. Maintain contact precautions.
- D. Apply cloth diapers.
Correct Answer: C
Rationale: prevents transmission of this bacterium to other individuals
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The nurse in the outpatient clinic teaches a young adult with a sprained right ankle to walk with a cane. While teaching the client to use the cane, how should the nurse be positioned?
- A. Standing on the client's left side and slightly behind the client.
- B. Standing on the client's right with one hand on the client's waist.
- C. Standing directly in front of the woman with both hands on the client's arms.
- D. Standing in front of the client on the right side.
Correct Answer: A
Rationale: stand slightly behind patient on strong side
The nurse is preparing to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique?
- A. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter.
- B. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn.
- C. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway.
- D. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.
Correct Answer: C
Rationale: break in sterile procedure, suction mouth after trachea
The nurse is caring for clients in the pediatric clinic.
- A. Which finding in a six-month-old infant requires follow-up?
- B. The anterior fontanel is open.
- C. The child is not sitting unsupported.
- D. The child is not pulling to a standing position.
- E. The child is not rolling from abdomen to back.
Correct Answer: C
Rationale: By six months, infants typically pull to a standing position with support. Failure to do so may indicate developmental delay, requiring follow-up. An open anterior fontanel is normal until 18 months, sitting unsupported begins around 7-8 months, and rolling over is expected by 5-6 months.
The nurse is caring for a client after an ileostomy. The nurse would be MOST concerned if which of the following was observed?
- A. The ileostomy functions without daily irrigations.
- B. The stoma appears to be tight, and there is a decreased amount of stool.
- C. A small amount of mucus is seen around the anal area.
- D. There is weight gain of 5 lb over a three-week period of time.
Correct Answer: B
Rationale: important to report these findings to the physician; may indicate an obstruction or stoma stricture
The nurse is caring for a 34-year-old man admitted with low back pain. The history indicates that the patient has hemophilia A. The nurse should question which of the following orders?
- A. Ketorolac tromethamine (Toradol).
- B. Codeine phosphate (Paveral).
- C. Oxycodone terephthalate (Percodan).
- D. Hydromorphone hydrochloride (Dilaudid).
Correct Answer: C
Rationale: contraindicated for persons with bleeding disorders, contains aspirin