Nokea
Which statements involve acceptable use of an abbreviation, symbol, or dose designation in documentation? Select all that apply.
- A. 7 cm x 3 cm x 1 cm stage II decubitus noted on left shin.
- B. 40 u SSRI administered to cover capillary glucose of 160 mg/dL.
- C. Dose of 0.5 mg hydromorphone administered and the client feels better.
- D. 4 Maalox 5 mL PO administered pc as requested for c/o heartburn.
- E. Spouse voiced understanding of home urinary catheterization QID.
Correct Answer: A
Rationale: Metric units (A), decimal doses (C), and QID (E) are clear and acceptable. 'u' (B) risks confusion with '0,' and 'pc' with 'c/o' (D) are ambiguous, per safety standards.
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To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed with the legs suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow with the legs suspended parallel to the bed
- D. Hips and legs are flat on the bed with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to align the femur properly and reduce pressure on the pelvis.
The nurse is talking with the parent of a 15-month-old client who is scheduled to receive the varicella vaccine. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. Your child may develop a low-grade fever after receiving the vaccine
- B. Your child can have aspirin to decrease discomfort caused by the vaccine.
- C. Your child may develop a rash at the injection site after receiving the vaccine.
- D. Your child will require a second dose of the vaccine at a subsequent visit.
- E. Your child should not receive any other vaccines at the same visit.
Correct Answer: A,C,D
Rationale: The varicella vaccine may cause a low-grade fever (A) or a rash at the injection site (C) as common side effects. A second dose (D) is required at 4-6 years for full immunity. Aspirin (B) is contraindicated in children due to Reye’s syndrome risk. Other vaccines (E) can be given concurrently, per CDC guidelines, unless contraindicated.
A client diagnosed with endometrial cancer is receiving brachytherapy. Which interventions should the nurse anticipate for this client? Select all that apply.
- A. Cluster care to limit each staff member's time in the room
- B. Instruct the client to be up and around in the room but not to leave the room
- C. Remind family members and visitors to limit close contact with the client
- D. Use protective shielding, if available, when providing direct client care
- E. Wear a radiation badge while in the client's room to measure radiation exposure
Correct Answer: A,C,D,E
Rationale: Brachytherapy involves internal radiation, requiring precautions to minimize exposure. Clustering care (A) reduces staff exposure time. Limiting visitor contact (C) protects others from radiation. Protective shielding (D) and radiation badges (E) ensure safety and monitor exposure. Ambulation (B) is restricted to prevent dislodging the radiation source.
The nurse is reviewing lifestyle and nutritional strategies to help cables symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.
- A. Choose foods that are low in fat
- B. Do not consume any foods containing dairy
- C. Eat three large meals a day and minimize snacking
- D. Limit or eliminate the use of alcohol and tobacco
- E. Try to avoid caffeine, chocolate, and peppermint
Correct Answer: A,D,E
Rationale: GERD management focuses on reducing esophageal irritation. Low-fat foods (A) reduce gastric acid secretion and reflux risk. Limiting alcohol and tobacco (D) prevents lower esophageal sphincter relaxation and mucosal irritation. Avoiding caffeine, chocolate, and peppermint (E) minimizes sphincter relaxation. Dairy (B) is not universally contraindicated unless lactose intolerance is present. Large meals (C) increase gastric pressure, worsening reflux.
After a recent outbreak of varicella in an elementary school, the practical nurse is assisting with the development of an informative letter to parents. Which of the following instructions are appropriate to include? Select all that apply.
- A. Apply calamine lotion to soothe lesions
- B. Clip your child’s fingernails short
- C. Ensure that your child’s vaccinations are up to date
- D. Keep your child home until lesions have crusted
- E. Place mittens on your child’s hands when sleeping
Correct Answer: A,B,C,D,E
Rationale: Calamine lotion (A) relieves itching, short nails (B) and mittens (E) prevent scratching, vaccinations (C) protect against future infection, and isolation until crusted (D) prevents transmission. All are appropriate.