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A 14-month-old child has a severe diaper rash. Which of the following recommendations should the nurse provide to the parents?
- A. Continue to use the baby wipes.
- B. Change the diaper every 4 to 6 hours.
- C. Wash the buttocks using mild soap.
- D. Apply powder to the diaper area.
Correct Answer: C
Rationale: Mild soap cleanses without irritating the rash, promoting healing, unlike wipes or powder, which may worsen it.
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The nurse is caring for a client with an injury to the thalamus. The nurse should plan to:
- A. Give higher doses of pain medication.
- B. Keep patches on the client's eyes to prevent corneal abrasion.
- C. Monitor the temperature of the bathwater.
- D. Avoid turning the client.
Correct Answer: C
Rationale: The thalamus regulates body temperature, so an injury may impair thermoregulation. Monitoring bathwater temperature prevents burns or discomfort. Pain medication, eye patches, or avoiding movement are not directly related to thalamic injury.
The nurse is performing an assessment on a 6-month-old infant suspected of having hydrocephalus. Which finding is associated with this diagnosis?
- A. A bulging anterior fontanel
- B. An elevated apical heart rate
- C. The presence of protein in the urine
- D. A drop in blood pressure from baseline
Correct Answer: A
Rationale: A bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle, which occurs in hydrocephalus. An elevated apical heart rate, proteinuria, and a drop in blood pressure are not specifically related to increasing cerebrospinal fluid in the brain tissue.
The nurse is teaching a client with a new diagnosis of type 2 diabetes mellitus about dietary modifications. Which of the following foods should the client limit?
- A. Whole grains.
- B. Sugary beverages.
- C. Lean proteins.
- D. Non-starchy vegetables.
Correct Answer: B
Rationale: Sugary beverages should be limited in type 2 diabetes to prevent blood glucose spikes.
Which of the following patient care tasks is coupled with the appropriate member of the nursing care team in terms of their legal scope of practice?
- A. An unlicensed staff member who has been 'certified' by the employing agency to monitor telemetry: Monitoring cardiac telemetry
- B. An unlicensed assistive staff member like a nursing assistant who has been 'certified' by the employing agency to insert a urinary catheter: Inserting a urinary catheter
- C. A licensed practical nurse: The circulating nurse in the perioperative area
- D. A licensed practical nurse: The first assistant in the perioperative area
Correct Answer: A
Rationale: Monitoring cardiac telemetry is within the scope of practice for unlicensed staff who are specifically trained and certified by the employing agency. Inserting a urinary catheter typically requires a higher level of licensure (e.g., LPN or RN), and LPNs are not typically authorized to serve as circulating nurses or first assistants in the perioperative area, as these roles require advanced training or RN licensure.
A client with a history of gout is prescribed febuxostat (Uloric). The nurse should monitor the client for which of the following adverse effects?
- A. Hepatotoxicity.
- B. Hypoglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Febuxostat can cause hepatotoxicity, requiring liver function monitoring.