Nokea
You are educating a mother about the association between autism and the MMR vaccine. You know that the mother understands your instructions when she says:
- A. My child should not get the vaccine since it is known to cause autism.
- B. My child should get the individual immunizations for measles, mumps, and rubella since the individual vaccines do not cause autism.
- C. My child should get the MMR immunization since there is no evidence that it causes autism.
- D. My child should not get the immunization because it contains mercury.
Correct Answer: C
Rationale: Extensive research shows no link between MMR and autism, and MMR does not contain mercury. Individual vaccines are not standard, and avoiding vaccination is unsafe.
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The nurse is performing hand hygiene. Which actions should the nurse take when washing their hands with soap and water? Select all that apply.
- A. Use a paper towel to turn off the faucet.
- B. Keep the hands and forearms lower than the elbows during washing.
- C. Wash hands using hot water.
- D. Rinse the hands and wrists by keeping the hands down and elbows up.
- E. Wash hands for 5 to 10 seconds.
Correct Answer: A,B,D
Rationale: Using a paper towel, keeping hands lower, and rinsing correctly prevent contamination. Hot water is harsh, and washing should last 40-60 seconds.
The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
- A. Diabetes insipidus
- B. Cushing's syndrome
- C. Hemophilia
- D. Inflammatory bowel disease
Correct Answer: B
Rationale: Cushing’s syndrome involves elevated cortisol levels, which impair wound healing by suppressing immune responses and collagen synthesis. Diabetes insipidus primarily affects fluid balance, hemophilia affects clotting but not healing directly, and inflammatory bowel disease is less directly related to wound healing compared to Cushing’s syndrome.
The nurse is removing an indwelling urinary catheter
Item 1 of 1
Nurses Note
The removal of the client’s indwelling urinary catheter was attempted. Perineal hygiene was performed before the removal. The urine collection bag was emptied with 450 mL of clear, straw-colored urine. 2 mL of fluid was removed during the deflation of the balloon. Resistance was felt when the tubing was removed, and the client reported discomfort.
Drag words from the choices below to fill the blank in the following sentence. Prior to attempting to remove the catheter again, the nurse should--------------------------
- A. place a warm compress over the perineum
- B. cut the balloon inflation valve
- C. position the client at 45 degrees
- D. further deflate the catheter balloon
Correct Answer: D
Rationale: The amount of fluid removed from the balloon (this secures the catheter in place inside of the bladder) was inadequate. 10 mL of fluid is typically used to inflate the catheter balloon to keep it secure inside the bladder. The nurse should further deflate the catheter balloon by passively allowing the fluid to fill the syringe. The nurse may gently pull back on the syringe plunger if this does not work. By removing the residual volume, the nurse should then remove the catheter.
Cutting the balloon inflation valve would negate the closed system. Cutting the valve is not standard practice and should not be done. Positioning the client 45 degrees is not appropriate for discontinuing an indwelling urinary catheter. The correct approach for positioning a client to remove an indwelling catheter is having a male client supine and a female in the dorsal recumbent position.
Placing a warm compress over the perineum may give the client comfort, but this will not effectively troubleshoot the problem with the catheter. The issue is not with a bladder spasm, yet an indwelling urinary catheter that has not been entirely deflated.
The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?
- A. Spills sterile water onto the sterile field
- B. Uses sterile gloves to handle sterile supplies on a sterile field
- C. Has sterile gauze placed into the sterile field
- D. Keeps the sterile field above their waist
Correct Answer: A
Rationale: Spilling sterile water contaminates the sterile field, requiring follow-up. Other actions are consistent with aseptic technique.