The nurse is providing education on tick removal. Which action would be incorrect?
Cleanse the wound with soap and water.
Grasp the tick by the body to remove.
Leave the tick in place and seek emergency medical treatment.
Avoid touching the tick with bare hands.
The Correct Answer is B
The correct answer is choice b. Grasp the tick by the body to remove.
Choice A rationale:
Cleansing the wound with soap and water is a correct action. It helps to prevent infection after the tick has been removed.
Choice B rationale:
Grasping the tick by the body is incorrect. The proper method is to use fine-tipped tweezers to grasp the tick as close to the skin’s surface as possible and pull upward with steady, even pressure. Grasping the tick by the body can cause the mouth-parts to break off and remain in the skin, increasing the risk of infection.
Choice C rationale:
Leaving the tick in place and seeking emergency medical treatment is not recommended. The tick should be removed as soon as possible to reduce the risk of disease transmission.
Choice D rationale:
Avoiding touching the tick with bare hands is correct. Using gloves or tissue to handle the tick helps prevent the transmission of pathogens.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D: Jaundice.
Choice A rationale:
Vomiting can occur in biliary atresia due to the blockage of bile flow, but it is not the earliest clinical manifestation. Jaundice tends to precede vomiting and is a more characteristic early sign of biliary atresia.
Choice B rationale:
Hepatomegaly (enlargement of the liver) is a common finding in biliary atresia, but it usually occurs after the onset of jaundice. Jaundice is an earlier and more specific manifestation of this condition.
Choice C rationale:
Absence of stooling is a sign that might occur in biliary atresia due to the obstructed bile flow, but it is not typically the earliest clinical manifestation. Jaundice is generally the first noticeable sign.
Choice D rationale:
Jaundice is the earliest clinical manifestation of biliary atresia. It is caused by the buildup of bilirubin in the blood due to impaired bile flow from the liver. The jaundice in biliary atresia is typically progressive and can be one of the key indicators for further evaluation and diagnosis.
Correct Answer is A
Explanation
The correct answer is choice A. Potassium.
Choice A rationale:
Diuretics like furosemide are commonly used to treat congestive heart failure. They work by increasing the excretion of water and electrolytes, including potassium, from the body. Low levels of potassium (hypokalemia) can lead to various complications, including cardiac arrhythmias and muscle weakness. Since furosemide can cause potassium loss, it's important to ensure an adequate intake of potassium-rich foods. Bananas, oranges, and leafy vegetables are excellent sources of potassium. Therefore, the nurse encourages the family to include these foods in the child's diet to help maintain a healthy potassium balance.
Choice B rationale:
Sodium is an important electrolyte, but in the context of congestive heart failure and diuretic use, the focus is more on avoiding excessive sodium intake. Diuretics like furosemide aim to reduce fluid retention by increasing sodium excretion, so it's not necessary to recommend high-sodium foods. Moreover, excessive sodium intake could exacerbate fluid retention and worsen the heart failure.
Choice C rationale:
Chlorides are often found in table salt (sodium chloride) and are not typically emphasized in the context of heart failure treatment or diuretic use. While they play a role in maintaining electrolyte balance, they are not the primary focus in this scenario.
Choice D rationale:
Zinc is a mineral that is not directly related to the treatment of congestive heart failure or the use of diuretics. It is important for various cellular functions and immune system support, but it's not the electrolyte of concern in this situation.
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