Nokea
Because of the length of time the client must remain in skeletal traction, the nurse correctly assesses for evidence of skin breakdown in which area?
- A. Over the child's calves
- B. Over the child's scapulae
- C. On the child's knees
- D. On the child's buttocks
Correct Answer: D
Rationale: Prolonged immobility in traction increases pressure on the buttocks, a common site for skin breakdown due to constant contact with the bed.
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. A new mother of a full-term, 7-lb newborn asks the nurse how to ensure that her baby is taking the correct amount of formula at each feeding. The nurse explains that the infant needs approximately 3 ounces of fluid per pound of body weight per day. How many ounces of formula should her infant be eating every 4 hours? _________ ounces (Record your answer to the nearest tenth.)
Correct Answer: 3.5
Rationale: Multiplying 3 oz by 7 lb = 21 oz/day. Dividing 21 oz by 6 feedings (every 4 hours) = 3.5 oz per feeding.
While supervising the LPN,the RN determines that the LPN needs additional instruction in newborn care. Which action by the LPN prompted the nurse’s conclusion?
- A. Assessed the newborn’s heart rate apically
- B. Covered the newborn’s head with a stocking cap
- C. Checked the newborn’s temperature rectally
- D. Positioned the newborn supine while sleeping
Correct Answer: C
Rationale: Rectal temperature checks risk mucosal irritation or perforation. Apical HR assessment stocking caps and supine positioning (to reduce SIDS risk) are correct practices.
The nurse discovers that an African couple from Kenya has not named their 48-hour-old,full-term newborn and the infant and mother are being discharged to home. Which action should the nurse take in response to this information?
- A. Ask the parents to choose a name before discharge.
- B. Encourage other appropriate attachment behaviors.
- C. Document the discharge and that the baby is unnamed.
- D. Delay discharge until parental attachment is addressed.
Correct Answer: C
Rationale: In Kenyan culture naming may occur on the third day with celebration. Documenting the discharge and unnamed status is appropriate; naming isn’t required for attachment.
When caring for a child with measles, which precaution is most appropriate for the nurse to implement?
- A. Standard precautions
- B. Droplet precautions
- C. Contact precautions
- D. Airborne precautions
Correct Answer: D
Rationale: Measles is highly contagious and spreads via airborne transmission, requiring airborne precautions, including a negative-pressure room and N95 respirator use.
When preparing the adolescent for the examination, the nurse correctly explains that a specimen should be collected and sent to the laboratory. Which specimen should the nurse collect?
- A. Blood sample
- B. Urine sample
- C. Vaginal smear
- D. Biopsy of the cervix
Correct Answer: C
Rationale: A vaginal smear is appropriate for diagnosing gonorrhea in females, allowing culture or nucleic acid testing of cervical or vaginal secretions to detect Neisseria gonorrhoeae.