Nokea
Which question is most important for the nurse to ask the adolescent girl in preparation for X-rays?
- A. Is there any possibility that you're pregnant?
- B. Have you eaten anything in the past 24 hours?
- C. Have you taken any medications in the past 24 hours?
- D. Are you allergic to iodine or shellfish?
Correct Answer: A
Rationale: Asking about pregnancy is critical before X-rays, as radiation can harm a fetus, making it the most important question to ensure safety.
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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.
When caring for a child with measles, which precaution is most appropriate for the nurse to implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: D
Rationale: Measles is highly contagious and spreads via airborne transmission, requiring airborne precautions, including a negative-pressure room and N95 respirator use.
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
A primigravida is in second stage of labour for the past two hours. Fetal head is at +1 station. Inspite of effective uterine contractions,mother is unable to push as she is exhausted. What will be the next step in her management:
- A. Wait for another one hour.
- B. Give sedation to the mother.
- C. Shift her for emergency section.
- D. Instrumental delivery.
- E. Call the anaesthetist for regional anaesthesia.
Correct Answer: D
Rationale: Instrumental delivery (e.g. forceps or vacuum) is indicated for prolonged second stage due to maternal exhaustion provided the fetal head is engaged (+1 station). Cesarean section is considered if instrumental delivery is not feasible.
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.