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Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?
- A. A temperature of 98.6°F (37.2°C) that occurs during the evening
- B. The child cannot recall items eaten for lunch the previous day
- C. The child vomits after awakening from a nap and again 1 hour later
- D. The VP shunt is palpable along the posterolateral portion of the skull
Correct Answer: C
Rationale: Persistent vomiting (C) suggests shunt malfunction or increased intracranial pressure, requiring immediate reporting. Normal temperature (A), memory lapses (B), and palpable shunt (D) are not concerning.
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Which of these statements best describes the characteristic of an effective reward-feedback system?
- A. Specific feedback is given as close to the event as possible
- B. Staff are given feedback in equal amounts over time
- C. Positive statements precede a negative statement
- D. Performance goals should be higher than what is attainable
Correct Answer: A
Rationale: Feedback is most useful when given immediately. Positive behavior is strengthened through immediate feedback, and it is easier to modify problem behaviors if what constitutes appropriate behavior is clearly understood.
A student nurse performs morning rounds and obtains a urine specimen from a client with methicillin-resistant Staphylococcus aureus who is in contact precautions. The nurse preceptor intervenes when the student performs which action?
- A. Cleans the stethoscope with 2% chlorhexidine solution before removing it from the room
- B. Removes the urine specimen cup from the room in a sealed, leak-proof bag
- C. Scrubs the Foley catheter collection port with alcohol for 15 seconds before withdrawing a urine specimen
- D. Uses an alcohol-based hand antiseptic after removing gloves
Correct Answer: A
Rationale: Chlorhexidine (A) is not standard for stethoscope cleaning in contact precautions; alcohol or approved disinfectants are used to prevent MRSA transmission. Sealed bags for specimens (B), scrubbing the port (C), and hand hygiene (D) are correct actions to maintain infection control.
When planning care for a woman who is admitted in labor, it is most important for the nurse to obtain which of the following information about the client?
- A. Age of the client and due date
- B. Frequency and duration of contractions
- C. Whether the membranes have ruptured
- D. Who will be assisting the woman during labor
Correct Answer: B
Rationale: Contraction frequency and duration indicate labor progress and urgency, guiding immediate care. Age, due date, membrane status, and support persons are secondary.
A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?
- A. 2+ pitting edema of the extremity with the arteriovenous fistula
- B. Loud swooshing sound auscultated over the arteriovenous fistula
- C. Pale skin of the hand of the arm with the arteriovenous fistula
- D. Surgical site pain reported by the client as 3 on a scale of 0-10 during hand exercises
Correct Answer: C
Rationale: Pale skin in the hand (C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (A) is common, a swooshing sound (B) indicates patency, and mild pain (D) is expected.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.