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1. A nurse is reinforcing teaching about home care for conjunctivitis with the parent of a school-age child. Which of the following information should the nurse include?
- A. Use a separate washcloth for the child
- B. Apply cold compresses to the eyes
- C. Apply warm compresses to the eyes
- D. Keep the child home until symptoms have resolved
Correct answer: A
Rationale: The correct answer is to use a separate washcloth for the child. This is important to prevent the spread of infection when a child has conjunctivitis. Using the same washcloth can lead to cross-contamination and further spread of the condition. Applying cold or warm compresses may provide comfort but do not address the prevention of spreading the infection. Keeping the child home until symptoms have resolved may be necessary, but the primary focus should be on preventing the spread of the infection within the household.
2. What are the signs of an acute myocardial infarction?
- A. Chest pain radiating to the arm and shortness of breath
- B. Nausea, vomiting, and high fever
- C. Headache, confusion, and low blood pressure
- D. Increased heart rate and bradycardia
Correct answer: A
Rationale: The correct answer is A: Chest pain radiating to the arm and shortness of breath. These are classic signs of an acute myocardial infarction. Choice B is incorrect because nausea, vomiting, and high fever are not typical signs of a heart attack. Choice C is incorrect as headache, confusion, and low blood pressure are not specific to myocardial infarction. Choice D is incorrect because an acute myocardial infarction typically presents with an increased heart rate, not bradycardia.
3. A client at 20 weeks of gestation is being taught by a nurse about an alpha-fetoprotein (AFP) test. Which of the following information should the nurse include?
- A. This test is used to confirm pregnancy
- B. This test is used to detect neural tube defects
- C. This test will determine the baby's lung maturity
- D. This test will check for gestational diabetes
Correct answer: B
Rationale: The correct answer is B: 'This test is used to detect neural tube defects.' An alpha-fetoprotein test is essential for screening neural tube defects in the fetus, not for confirming pregnancy, determining lung maturity, or checking for gestational diabetes. Detecting neural tube defects is crucial for early intervention and management of potential health issues in the baby.
4. What is the first intervention for a patient in shock?
- A. Administer fluids
- B. Monitor blood pressure
- C. Provide oxygen
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.
5. A nurse is caring for a client who is being discharged home following a cerebrovascular accident. Which of the following documents should the nurse plan to include with the discharge report?
- A. List of prescribed medications
- B. Potential complications to report
- C. Family contact details
- D. Dietary restrictions
Correct answer: B
Rationale: The correct answer is B: Potential complications to report. Including potential complications in the discharge report is crucial for ensuring proper follow-up care. This information helps the client and their caregivers to be aware of warning signs that may indicate a worsening condition or the need for immediate medical attention. Choices A, C, and D are important aspects of discharge planning, but providing a list of potential complications to report takes precedence as it directly impacts the client's safety and well-being post-discharge.
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