Nokea
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
- A. Use an automated lancet device to puncture the heel.
- B. Apply limb restraints to the infant.
- C. Puncture the heel at the inner aspect of the heel.
- D. Cleanse the area with povidone iodine.
Correct Answer: A
Rationale: An automated lancet device ensures a controlled puncture, minimizing discomfort. Restraints are unnecessary, the inner heel is not the correct site, and povidone iodine is not typically used for heel sticks.
You may also like to solve these questions
A nurse is caring for an adolescent who reports manifestations of an STI. Which of the following actions should the nurse take?
- A. Request that the adolescent sign a consent for treatment form prior to performing STI screening.
- B. Instruct the adolescent that a guardian must be present to provide consent for STI screening.
- C. Plan to notify the adolescent's guardian if the STI screening comes back positive.
- D. Obtain phone consent from the guardian of the adolescent prior to performing STI screening.
Correct Answer: A
Rationale: Adolescents can consent to STI screening in many jurisdictions, respecting their privacy. Guardian involvement may deter care, and notification breaches confidentiality unless required.
A nurse is making a home visit to a 5-year-old child who has cerebral palsy and uses a wheelchair. Which of the following observations made by the nurse indicates that the family needs support and resources to cope with the child's condition?
- A. A grandparent is assisting the child in performing ADLs.
- B. The child is playing a game with their siblings.
- C. The parent is withdrawn and rarely interacts with the child.
- D. The step-parent is helping the child prepare to transition into school.
Correct Answer: C
Rationale: A withdrawn parent suggests emotional distress or difficulty coping, indicating a need for support. Grandparent assistance, sibling play, and step-parent involvement reflect positive family engagement.
A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has a cleft lip and is bottle fed. Which of the following statements the guardian indicates that the teaching was effective?
- A. I will wait to burp my baby until after the feeding is finished.
- B. I will use a narrow-based nipple to feed my baby.
- C. I will hold my baby in an upright position during feedings.
- D. I will allow my baby's cheeks to remain relaxed during feeding.
Correct Answer: C
Rationale: Upright positioning prevents milk entering nasal passages in cleft lip infants. Delaying burping, narrow nipples, or relaxed cheeks are less effective.
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
- A. Insomnia
- B. Irritability
- C. Diarrhea
- D. Hypothermia
Correct Answer: B
Rationale: Irritability may signal increased intracranial pressure post-head injury, requiring prompt reporting. Insomnia, diarrhea, and hypothermia are less directly related.
A nurse is assisting with the care of an infant who requires emergency surgery and whose parent is an emancipated adolescent. Which of the following people can sign the informed consent form for the procedure?
- A. The parent of the adolescent parent
- B. The adolescent parent
- C. The infant's provider
- D. The adult sibling of the adolescent parent
Correct Answer: B
Rationale: An emancipated adolescent parent has legal authority to consent for their child's procedure. Others lack this authority unless legally designated.