A nurse is reinforcing teaching to the parent of a 6 year-old with a urinary tract infection on how to avoid repeat infections. Which statements by the parent indicate that the teaching has been effective? Select all that apply.
- A. I just bought my child new nylon panties.
- B. I will make sure my child does not hold urine.
- C. I will not give my child any more bubble baths.
- D. I will teach my child to wipe from the front to the back.
- E. I will use antibacterial soap for bathing my child.
Correct Answer: B,C,D
Rationale: Nylon panties can trap moisture, increasing infection risk; cotton is preferred. Not holding urine prevents bacterial growth. Avoiding bubble baths reduces irritation. Wiping front to back prevents bacterial spread. Antibacterial soap may disrupt natural flora, increasing infection risk.
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The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?
- A. Assist the client to the shower and provide directions to use antibacterial soap
- B. Delay the bath until the client has received antibiotic therapy for 24 hours
- C. Use a bath basin with warm water and a new washcloth for each body area
- D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client
Correct Answer: D
Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.
Laboratory reference ranges
BUN
10-20 mg/dL
(3.6-7.1 mmol/L)
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
The nurse is administering a cleansing enema to a client the night before bowel surgery. When administering the enema, the client reports cramping and pain. Which of the following actions should the nurse take?
- A. Slowly raise the height of the solution container
- B. Tell the client that the process will not take much longer
- C. Temporarily stop instilling the solution, then resume at a slower rate
- D. Withdraw the tube approximately 2 cm and continue the instillation
Correct Answer: C
Rationale: Pausing and slowing the flow reduces cramping by allowing the bowel to adjust. Raising the container increases pressure, reassurance doesn't address pain, and withdrawing the tube is unnecessary.
A 9-year-old client has terminal cancer, but the parents do not want the child to know the prognosis. Over the past days, the child has started asking questions such as what dying is like and whether the child will die. Which of the following actions by the nurse is most appropriate?
- A. Encourage the parents to openly discuss the child's questions
- B. Notify the health care provider about the child's questions
- C. Remind the child that everyone is trying to help the child get better
- D. Tell the child to ask the parents the questions about death
Correct Answer: A
Rationale: Encouraging parental discussion supports the child's emotional needs and honesty. Notifying the provider , reassuring falsely , or redirecting avoid addressing the child's questions.
The nurse is caring for a client who has gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for developing
- A. jaw necrosis
- B. vision changes
- C. gait disturbance
- D. Clostridoides difficile infection
Correct Answer: D
Rationale: Long-term omeprazole increases risk of C. difficile due to altered gut flora. Jaw necrosis , vision changes , and gait disturbance are not associated.
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