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A nurse is reinforcing teaching with a client who is postpartum about keeping her newborn safe while in the facility. Which of the following instructions should the nurse include in the teaching?
- A. Carry your newborn back to the nursery in your arms when you need to rest.
- B. Request that the nurses show their nursing license prior to removing your newborn from the room.
- C. Alert the staff if any of your newborn's identification bands are missing.
- D. Leave your newborn in the bassinet in your room while you use the bathroom.
Correct Answer: C
Rationale: Missing ID bands increase abduction risk, requiring immediate staff notification.
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A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
- A. Moves objects to mouth
- B. Anterior fontanel closed
- C. Rolls from back to abdomen
- D. Posterior fontanel closed
Correct Answer: B
Rationale: Anterior fontanel closure before 12-18 months may indicate abnormal development.
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 applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
- A. Place the client in a sitting position.
- B. Tie the restraint to the railing of the client's bed.
- C. Ensure the restraint is placed across the client's chest.
- D. Apply the restraint under the client's clothes.
Correct Answer: A
Rationale: Placing the client in a sitting position ensures safety and proper restraint application.
A nurse at a long-term care facility is reviewing the plan of care for a client who has a prescription for mitten restraints. Which of the following tasks should the nurse assign to an assistive personnel?
- A. Evaluate the need for the client to remain in mitten restraints.
- B. Determine the circulation status of the affected extremities every 2 hr.
- C. Instruct the client's family about the purpose of mitten restraints.
- D. Assist the client with range-of-motion exercises of the hands.
Correct Answer: D
Rationale: Assisting with range-of-motion is within the AP's scope, unlike evaluation or teaching.
A nurse in an acute care setting is assisting in collecting client information to include in a referral for a physical therapist. Which of the following information should the nurse plan to include?
- A. Family medical history
- B. Medications taken prior to admission
- C. Physical assessment findings
- D. Medical health insurance claim
Correct Answer: C
Rationale: Physical assessment findings inform the therapist's treatment plan.