Nokea
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important because rugs with rubber backs are less likely to slip, reducing the risk of falls for the older adult post knee replacement surgery. Choice A is incorrect as wearing shoes at home can increase the risk of falls due to slippery surfaces. Choice B is incorrect as placing a throw rug over electrical cords can create a tripping hazard. Choice C is incorrect as marking the edges of the doorway with tape does not address the risk of tripping over rugs.
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A nurse on the pediatric unit is admitting the child from the emergency department. Complete the following sentence by using the lists of options. The nurse suspects the child is experiencing rheumatic fever. The nurse should recognize the child is at greatest risk of developing--- due to---
- A. Glomerulonephritis
- B. Pericarditis
- C. Rheumatic heart disease
- D. Streptococcal pharyngitis
- E. Recent immunizations
- F. Viral infection
Correct Answer: C,D
Rationale: The correct answers are C: Rheumatic heart disease and D: Streptococcal pharyngitis. Rheumatic fever is caused by untreated streptococcal infection. If not treated promptly, it can lead to rheumatic heart disease, a serious complication. Streptococcal pharyngitis is a common precursor to rheumatic fever. Glomerulonephritis (A) is a potential complication of streptococcal infection but not directly related to rheumatic fever. Pericarditis (B) is an inflammation of the pericardium and not directly associated with rheumatic fever. Recent immunizations (E) and viral infections (F) are not linked to the development of rheumatic fever.
A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the head of the bed at a 30° angle.
- B. Offer sips of water due to having surgery.
- C. Log roll the adolescent every 2 hours.
- D. Assist the adolescent to ambulate 12 hours following surgery.
Correct Answer: C
Rationale: The correct answer is C: Log roll the adolescent every 2 hours. This is important to prevent pressure ulcers and maintain spinal alignment post-surgery. Log-rolling involves turning the patient as a unit to avoid twisting the spine. Maintaining the head of the bed at a 30° angle (choice A) is important for respiratory function but not specific to spinal surgery. Offering sips of water (choice B) is generally appropriate after surgery but not specific to spinal instrumentation. Assisting the adolescent to ambulate (choice D) should be done gradually and with caution, typically starting with sitting on the bedside first, rather than a fixed time frame like 12 hours post-surgery.
A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures.
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. This should be the first action as it prioritizes the safety of the child. Seizure precautions involve ensuring a safe environment, such as removing any potential hazards and providing padding to prevent injury during a seizure. Collecting blood cultures (B) and obtaining a prescription for pain medication (A) can be important but are not as urgent as ensuring the child's safety in case of a seizure. Transporting the child for a CT scan (C) is not an immediate priority unless there is a critical need.
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
- A. Take pancrelipase.
- B. Complete oral hygiene.
- C. Eat a meal.
- D. Use an albuterol inhaler.
Correct Answer: D
Rationale: The correct answer is D: Use an albuterol inhaler. Prior to postural drainage, the client with cystic fibrosis should use an albuterol inhaler to help open up the airways and facilitate effective mucus clearance during the procedure. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier to breathe and improving the effectiveness of postural drainage. Pancrelipase (choice A) is taken with meals to aid in digestion, so it is not necessary before postural drainage. Completing oral hygiene (choice B) is important but not directly related to postural drainage. Eating a meal (choice C) may lead to discomfort during the procedure. The priority is to ensure clear airways with the use of the albuterol inhaler.
A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
- A. The risk of transmission decreases once my child is on zidovudine for 2 weeks
- B. My child will need to double his medications for the next 6 months.
- C. My child will need to repeat his childhood immunizations once he's in remission.
- D. I will ensure that my child is tested for tuberculosis every year.
Correct Answer: D
Rationale: The correct answer is D because regular testing for tuberculosis is crucial for individuals with HIV due to their increased risk of developing tuberculosis. This indicates the parent understands the importance of monitoring for potential complications. Choice A is incorrect because zidovudine does not impact transmission risk. Choice B is incorrect as doubling medications without healthcare provider guidance can be harmful. Choice C is incorrect as childhood immunizations are typically not repeated in remission.