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A nurse is caring for a preschooler who recently experienced the death of a parent. Which of the following findings should the nurse identify as consistent with this age group?
- A. Understands that everyone dies eventually
- B. Recognizes the parent will never wake up
- C. Expresses curiosity about the funeral service
- D. Believes death is punishment for bad behavior
Correct Answer: D
Rationale: Preschoolers often believe death is a punishment due to magical thinking. Understanding permanence or universal death is beyond their developmental stage.
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A nurse is assisting with preparing a client who is to have a central venous catheter inserted for the administration of total parenteral nutrition (TPN. Which of the following actions should the nurse take?
- A. Verify the amount of TPN solution the client is receiving every 4 hr.
- B. Prepare the client for a chest x-ray to verify catheter placement.
- C. Place the client in Sims' position for catheter insertion.
- D. Use a clean technique when changing the catheter dressing.
Correct Answer: B
Rationale: A chest X-ray confirms proper central venous catheter placement, critical for safe TPN administration. Verifying solution, Sims' position, or clean technique are inappropriate.
A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?
- A. You should lay down for 1 hour following a meal.
- B. You should eat three large meals and two snacks per day.
- C. You should only drink 2 cups of coffee per day.
- D. You should elevate the head of the bed while sleeping.
Correct Answer: D
Rationale: Elevating the bed head prevents acid reflux at night. Lying down post-meal, large meals, or coffee can worsen GERD symptoms.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
- A. Elevate the arm.
- B. Document the infiltration.
- C. Stop the infusion.
- D. Apply a warm compress.
Correct Answer: C
Rationale: Stopping the infusion is the priority to prevent further fluid infiltration, which can cause tissue damage. Elevation, documentation, and compresses follow after halting the infusion.
A nurse is caring for a client who is postoperative following a prostatectomy. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 2 hr.
- B. Instruct the client to resume a high-fiber diet immediately.
- C. Apply a cold pack to the perineal area.
- D. Encourage the client to sit for prolonged periods.
Correct Answer: A
Rationale: Monitoring urine output detects complications like obstruction. High-fiber diets resume gradually, cold packs aren't standard, and prolonged sitting risks discomfort.
A nurse is reinforcing teaching with a client who is scheduled for a colonoscopy. Which of the following statements should the nurse include?
- A. You will be given a sedative during the procedure.
- B. You can eat a light breakfast the morning of the procedure.
- C. You will need to maintain a clear liquid diet for 3 days prior to the procedure.
- D. You will need to take an antibiotic before the procedure.
Correct Answer: A
Rationale: A sedative is used to ensure comfort during a colonoscopy. Clear liquids are required only 1-2 days prior, no food is allowed the morning of, and antibiotics aren't standard.