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A nurse is reinforcing teaching with a new mother about facility security measures. Which of the following statements by the mother indicates an understanding of the teaching?
- A. I can remove my security band to give it to a family member.
- B. I will carry my baby to the nursery.
- C. I will have an identification band that matches the one my baby wears.
- D. I can take my baby to the lobby to visit family.
Correct Answer: C
Rationale: Matching identification bands ensure mother and baby are correctly paired, a key security measure. Removing bands, carrying to the nursery, or taking the baby to public areas risks safety.
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A nurse is reinforcing teaching about laboratory testing with a client. Which of the following findings should the nurse include as an indicator of infection?
- A. Decreased platelets
- B. Increased iron level
- C. Increased erythrocyte sedimentation rate
- D. Decreased hemoglobin
Correct Answer: C
Rationale: Increased ESR indicates inflammation, often due to infection. Platelet or hemoglobin decreases or iron increases aren't specific to infection.
A nurse is caring for a client in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Insert an oral airway into the client's mouth.
- B. Lower the side rails of the bed when the seizure begins.
- C. Measure the duration of the seizure.
- D. Restrain the client's arms and legs to prevent injury.
Correct Answer: C
Rationale: Measuring seizure duration aids in assessing severity and guiding treatment. Inserting airways, lowering rails, or restraining can cause injury or complications.
A nurse on a pediatric unit is caring for a toddler who has poor dietary intake. Which of the following actions should the nurse take first?
- A. Obtain the child's dietary history.
- B. Offer the child nutritious snacks between meals.
- C. Encourage the family to be with the child during mealtimes.
- D. Instruct the family to praise the child when they eat.
Correct Answer: A
Rationale: Obtaining a dietary history identifies patterns and causes of poor intake, guiding subsequent interventions like snacks or family involvement.
A nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse take?
- A. Check the ventilator settings every 8 hr.
- B. Suction the endotracheal tube every 4 hr.
- C. Monitor the client's oxygen saturation continuously.
- D. Administer a bronchodilator every 12 hr.
Correct Answer: C
Rationale: Continuous oxygen saturation monitoring ensures adequate ventilation. Settings checks, suctioning, and bronchodilators depend on specific needs, not fixed schedules.
A nurse is reinforcing teaching with a client who has a new prescription for amoxicillin. Which of the following instructions should the nurse include?
- A. Take this medication with an antacid to prevent stomach upset.
- B. You might experience diarrhea while taking this medication.
- C. You need to refrigerate this medication.
- D. You should stop taking this medication if you feel better.
Correct Answer: B
Rationale: Amoxicillin can cause diarrhea, a common side effect. Antacids aren't needed, refrigeration depends on form, and stopping early risks resistance.