Nokea
A nurse is assisting with teaching a class about the importance of fire safety. Which of the following hazards should the nurse include as an example of the leading cause of residential fires?
- A. Placing a space heater 5 ft from bed
- B. Smoking in bed
- C. Leaving the stove on
- D. Lack of smoke detectors
Correct Answer: B
Rationale: Smoking in bed is a leading cause of residential fires.
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The client has mild hypertension.
A nurse is reinforcing teaching about healthy lifestyle changes with a female client who has mild hypertension. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should exercise for 15 minutes two times per week.
- B. I should decrease my salt intake to 2 grams per day.
- C. I will set my blood pressure goal at 130 over 84.
- D. I can have two glasses of wine with dinner.
Correct Answer: B
Rationale: Reducing salt to 2 grams daily helps manage hypertension, showing understanding.
A nurse is verifying informed consent for a client who is preoperative for a vaginal hysterectomy. Which of the following statements should the nurse identify as an indication that the client has given informed consent?
- A. I will no longer need regular gynecological examinations.
- B. I will have a large scar on my stomach after this procedure.
- C. I am thankful I am done having children.
- D. I should expect my periods to resume in 1 month.
Correct Answer: C
Rationale: Expressing relief about no more children suggests understanding of the procedure's outcome.
A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?
- A. Tape the tube to the child's cheek.
- B. Attach an extension tube to the site's opening prior to use.
- C. Secure the tubing to the child's abdomen.
- D. Apply water-soluble lubricant to the site.
Correct Answer: C
Rationale: Securing the tube to the abdomen prevents dislodgement.
A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
- A. Thoroughly explain each procedure to the toddler.
- B. Start the examination with routine immunizations.
- C. Allow the toddler to handle the equipment.
- D. Completely undress the toddler.
Correct Answer: C
Rationale: Allowing the toddler to handle equipment reduces fear and increases cooperation.
A nurse is assisting with the plan of care for a 10-month-old infant who has HIV. Which of the following interventions should the nurse include in the plan?
- A. Educate the infant's guardians about exchange transfusion.
- B. Administer granulocyte colony-stimulating factor.
- C. Initiate droplet precautions.
- D. Monitor the infant's lymphocyte count.
Correct Answer: D
Rationale: Monitoring lymphocyte count tracks HIV progression in infants.