Nokea
A mother that has never breast-fed a child before is having trouble getting the baby to latch on to the breast. The baby has lost 3% of its birth weight within the first 2 days of life. The best statement is:
- A. The baby will eventually take to the breast.
- B. I can fix up a bottle if you want to try that.
- C. A small amount of weight loss in the first few days is normal.
- D. I can get the charge nurse to come and talk to you about breast-feeding.
Correct Answer: C
Rationale: 5-10% of birth weight loss following birth is normal for the first few days of life, and this response reassures the mother while allowing further discussion about breastfeeding challenges.
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Which of these clients would be the highest priority for the nurse to assign to a private room?
- A. A client with a new diagnosis of tuberculosis
- B. A client with a urinary tract infection
- C. A client post-appendectomy with a surgical site infection
- D. A client with seasonal influenza
Correct Answer: A
Rationale: A client with tuberculosis requires a private room with negative pressure to prevent airborne transmission of the disease.
All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct Answer: C
Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.
The nurse is demonstrating the use of a fire extinguisher during a fire drill. Place the steps for using a fire extinguisher in the correct order.
- A. Squeeze the handle
- B. Sweep from side to side
- C. Pull the pin
- D. Aim at the base of the fire
Correct Answer: C,D,A,B
Rationale: The PASS technique is: Pull the pin (C), Aim at the base (D), Squeeze the handle (A), Sweep side to side (B).
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
The client had a THR. The nurse is discussing home modifications with the client's son. Which modifications should the nurse recommend? Select all that apply.
- A. Pad bed side rails.
- B. Install safety bars around the toilet and shower.
- C. Install an elevated toilet seat in the bathroom.
- D. Plan for the client's bed to be in a main floor room.
- E. Use a nonskid bathmat in the bathtub for the client's daily bath.
- F. Remove scatter rugs and secure electrical cords against baseboards.
Correct Answer: B,C,D,F
Rationale: B: Safety bars aid mobility. C: Elevated toilet seat prevents excessive hip flexion. D: Main floor bedroom avoids stairs. F: Removing rugs and cords prevents tripping. A is unnecessary, and E is incorrect as tub baths are avoided post-THR.