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A nurse is reinforcing teaching about newborn care with a new guardian. Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will bathe my baby under a faucet of running water.
- B. I will wash my baby's face with a warm, wet washcloth without soap.
- C. I will wash my baby's head using a moist towelette.
- D. I will give my baby a bath every day.
Correct Answer: B
Rationale: Washing the face with a warm, wet washcloth without soap prevents irritation, showing understanding.
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The client states that she slipped on some water outside of the shower.
A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?
- A. Notify the client's provider.
- B. Measure the client's vital signs.
- C. Document the fall in the client's medical record.
- D. Complete an incident report.
Correct Answer: B
Rationale: Measuring vital signs assesses for immediate injury, the priority action.
A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should leave my steri-strips on until they fall off.
- B. I should expect to have nausea for several days.
- C. I should eat a high-fat diet for several weeks.
- D. I should expect to have diarrhea until my diet changes.
Correct Answer: A
Rationale: Leaving steri-strips on until they fall off promotes proper healing.
A nurse is contributing to the plan of care for a client who is experiencing delirium. Which of the following interventions should the nurse recommend?
- A. Offer the client several choices at mealtimes.
- B. Alternate daily caregivers.
- C. Avoid discussing the client's fears.
- D. Remind the client of the day and time often.
Correct Answer: D
Rationale: Frequent orientation to time reduces confusion in delirium.
A nurse is contributing to the plan of care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include?
- A. Monitor the client for 1 hr after meals.
- B. Weigh the client every 2 days.
- C. Check the client's vital signs two times per week.
- D. Allow the client 2 hr to finish meals.
Correct Answer: A
Rationale: Monitoring for 1 hour after meals prevents purging, a key intervention for anorexia.
The nurse notes that the skin around the catheter's insertion site is edematous and cool.
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. Document the infiltration
- B. Apply a warm compress
- C. Elevate the arm
- D. Stop the infusion
Correct Answer: D
Rationale: Stopping the infusion prevents further fluid extravasation.