Nokea
The nurse has explained safety precautions and infant care to a primigravida mother and observes the mother as she gives care to her newborn during the first two days of rooming-in. Which action indicates the mother understands the instruction?
- A. Aspirates the newborn's nares using a syringe
- B. Applies a dressing to the cord after the newborn's bath
- C. Breastfeeds the infant every hour during the night
- D. Positions the infant supine in the crib to sleep
Correct Answer: D
Rationale: Positioning the infant supine in the crib to sleep is the correct action that indicates the mother understands the instruction. This position is recommended to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice A is incorrect as it is not a routine or recommended practice to aspirate the newborn's nares using a syringe without a specific medical indication. Choice B is incorrect because applying a dressing to the cord after the newborn's bath is not a standard care practice. Choice C is incorrect because breastfeeding every hour during the night is excessive and not a recommended feeding schedule for a newborn.
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A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?
- A. Follow the prompts of the AED
- B. Apply the AED pads to the client's chest
- C. Wipe the client's chest dry
- D. Move the client from the bathroom
Correct Answer: B
Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.
When preparing the client for a thoracentesis, which action is essential for the nurse to take?
- A. Encourage the client to cough during the procedure
- B. Ask the client to void prior to the procedure
- C. Have the client lie in the prone position
- D. Determine if chest x-rays have been completed
Correct Answer: B
Rationale: The essential action for the nurse to take when preparing a client for a thoracentesis is to ask the client to void prior to the procedure. This step is crucial as it helps prevent discomfort and reduces the risk of accidental injury. Encouraging the client to cough during the procedure (Choice A) is inappropriate as it can affect the accuracy of the thoracentesis. Having the client lie in the prone position (Choice C) is incorrect; the procedure is typically performed with the client sitting upright or slightly leaning forward. While determining if chest x-rays have been completed (Choice D) is important, ensuring the client has emptied their bladder is more critical for their comfort and safety during the procedure.
During discharge teaching, the nurse discusses the parameters for weight monitoring with a client recently diagnosed with heart failure (HF). Which information is most important for the client to acknowledge?
- A. Weigh at the same time every day
- B. Report weight gain of 2 pounds (0.9kg) in 24 hours
- C. Maintain a daily weight record
- D. Limit dietary salt intake
Correct Answer: B
Rationale: The correct answer is B. Reporting a weight gain of 2 pounds in 24 hours is crucial for detecting fluid retention or worsening heart failure. This rapid weight gain indicates possible fluid overload, which can be a sign of worsening HF. Option A is not as critical as the timing of weighing can vary. Option C is important for tracking trends but does not emphasize the significance of a sudden weight gain. Option D is relevant for managing HF but does not address the immediate need for reporting rapid weight gain.
After receiving report, which client should the nurse assess last?
- A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
- B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
- C. An older client with a distended abdomen and no drainage from the nasogastric tube
- D. An adult client with rectal tube draining clear pale red liquid drainage
Correct Answer: D
Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.
In conducting the admission assessment for a client experiencing complications of long-term Parkinson's disease, which question by the nurse provides the best information about disease progression?
- A. Have you experienced any stiffness in your neck or shoulder?
- B. Do you notice any jerky-type movements of your arms?
- C. Have you ever been frozen to a spot and unable to move?
- D. Do you have any problems with your hands shaking?
Correct Answer: C
Rationale: The correct answer is C. Asking about being 'frozen to a spot and unable to move' is the most indicative of disease progression in Parkinson's disease. Freezing episodes are a common symptom in advanced stages, indicating a more severe progression of the disease. Choices A, B, and D focus on common symptoms of Parkinson's disease but do not specifically address the aspect of disease progression related to freezing episodes.