Solutions
1. A 9-month-old girl is in the pediatrician office because of a
diaper rash that is getting worse. The child has no fever, is bottle
fed and is in the 50% for weight and height for age. On
examination the nurse notes a soiled diaper with a strong
ammonia odor. The skin is beefy red with numerous
maculopapular lesions across the front. The lesions extend into
the skin folds and across the upper thighs. The child's axillary
temperature is 98.9° F, pulse = 80 beats/min, respirations =
28/min. Which of the following would the nurse discuss with the
mother? Select all that apply.
A. "Change the diaper as soon as it becomes wet or soiled."
B. "Use a hair dryer or heat lamp to dry the area."
C. "Use a super-absorbent disposable diaper if you can."
D. "Keep the skin dry."
E. "Wash the area often as possible using a wipe."
F. "Diapers that are unscented can be purchased."
G. "Apply ointment such as zinc oxide or petrolatum Correct
Answers A, C, D, G, H
1. A newborn is born with a myelomeningocele and a surgical
repair is planned for the next day. What actions would the nurse
take to care for the myelomonocyte sac before the surgical
repair? Select all that apply.
A. Apply a sterile, moist nonadherent dressing to the sac.
B. Take a rectal temperature every 2 hours before surgery.
C. Irrigate the sac and surrounding skin with chlorhexidine.
,D. Diaper the infant while making sure it does not touch the sac.
E. Maintain the legs in abduction with a pad between the knees.
F. Position the newborn in a prone position with hips slightly
flexed.
G. Place the newborn in an incubator or warmer without
clothing or cover. Correct Answers A, E, F, G
1. A patient is admitted to the hospital with a diagnosis of
diarrhea with dehydration. The nurse recognizes that increased
peristalsis resulting in diarrhea can be related to
a. sympathetic inhibition.
b. mixing and propulsion.
c. sympathetic stimulation.
d. parasympathetic stimulation. Correct Answers D
1. A patient with hepatitis A is in the acute phase. The nurse
plans care for the patient based on the knowledge that
a. itching is a common problem with jaundice in this phase.
b. the patient is most likely to transmit the disease during this
phase.
c. gastrointestinal symptoms are not as severe in hepatitis A as
they are in hepatitis B.
d. extrahepatic manifestations of glomerulonephritis and
polyarteritis are common in this phase. Correct Answers a
1. A patient with osteomyelitis undergoes surgical debridement
with implantation of antibiotic beads. When the patient asks why
the beads are used, the nurse answers (select all that apply)
,a. "Oral or IV antibiotics are not effective in most cases of bone
infection."
b. "The beads are an adjunct to debridement and antibiotics for
deep infections."
c. "The beads are used to deliver antibiotics directly to the site of
the infection."
d. "This is the safest method to deliver long-term antibiotic
therapy for bone infection."
e. "Ischemia and bone death related to osteomyelitis are
impenetrable to IV antibiotics." Correct Answers b, c
1. Indicate which type of precautions the nurse will place these
patients into in order to prevent transmission of various
pathogens.
Precautions: Transfusion-based, airborne, standard, droplet,
respiratory hygiene/cough etiquette, none
Patients:
A. 15-year-old returning from summer in India who presents
with symptoms of tuberculosis
B. 3-year-old who has a respiratory illness with cough
C. 5-year-old admitted with fever and productive cough;
bacterial pneumonia confirmed by lab and x-ray
, D. 7-year-old admitted tonsillectomy Correct Answers A:
Airborne precautions
B: Respiratory Hygiene/Cough etiquette
C: Droplet precautions
D: Standard precautions
1. M.J. calls the clinic and tells the nurse that her 85-yr-old
mother has been nauseated all day and has vomited twice.
Before the nurse hangs up and calls the HCP, she should tell
M.J. to
a. administer antiemetic drugs and assess her mother's skin
turgor.
b. give her mother sips of water and elevate the head of her bed
to prevent aspiration.
c. offer her mother large quantities of Gatorade to decrease the
risk for sodium depletion.
d. give her mother a high-protein liquid supplement to drink to
maintain her nutritional needs. Correct Answers b
1. The bone cells that function in the formation of new bone
tissue are called
a. osteoids.
b. osteocytes.
c. osteoclasts.
d. osteoblasts. Correct Answers d