Nokea
The nurse is caring for a hospitalized 6-month-old client. Which of the following interventions should the nurse implement to provide developmentally appropriate care for this client? Select all that apply.
- A. Adhere to the child's home routine when possible during hospitalization
- B. Encourage parents to bring the child's favorite toy from home
- C. Have the parents step out of the room during procedures
- D. Promote a quiet sleep environment with reduced stimuli
- E. Provide a parent's shirt for the child to hold during procedures
Correct Answer: A,B,D,E
Rationale: Following the home routine (A), providing familiar toys (B), ensuring a quiet sleep environment (D), and offering a parent's shirt (E) promote comfort and security for a 6-month-old.
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The nurse is walking through a crowded waiting room when the respiratory therapist approaches the nurse and asks, 'How is the client in room 312?' Which of the following responses would be most appropriate for the nurse to make?
- A. I will document my most recent assessment in the client's medical record for your review.
- B. Additional medications were prescribed to help improve the client's respiratory status.
- C. The client was doing much better when I last checked during hourly rounds.
- D. We need to move away from this area to discuss the client's status.
Correct Answer: D
Rationale: Discussing client information in a crowded area risks breaching confidentiality. Moving to a private area ensures compliance with HIPAA and protects client privacy.
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
- A. Ask the client if there are any breathing problems
- B. Have the client void as much as possible
- C. Check the vital signs
- D. Auscultate the lungs
Correct Answer: D
Rationale: All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However, the worst result is heart failure with lung congestion, so the auscultation of the lungs is the priority action.
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
- A. Excessive fetal weight
- B. Low blood sugar levels
- C. Depletion of subcutaneous fat
- D. Progressive placental insufficiency
Correct Answer: D
Rationale: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.
The nurse is providing postpartum teaching for a non-nursing mother. Which of the client's statements indicates the need for additional teaching?
- A. I'm wearing a support bra.
- B. I'm expressing milk from my breast.
- C. I'm drinking four glasses of fluid during a 24-hour period
- D. While I'm in the shower, I'll keep the water from running over my breasts
Correct Answer: B
Rationale: Non-nursing mothers should avoid expressing milk, as it stimulates further production. Support bras, adequate fluids, and avoiding breast stimulation are correct practices.
The nurse in a long-term care facility observes a nursing assistant caring for a resident who has a hearing aid and dentures. Which action by the nursing assistant should be corrected?
- A. The nursing assistant places a washcloth in the sink before brushing the client's dentures.
- B. The nursing assistant uses toothpaste to clean the dentures.
- C. The nursing assistant uses alcohol to wipe off the exterior of the hearing aid.
- D. The nursing assistant wipes the exterior of the hearing aid with a damp cloth.
Correct Answer: C
Rationale: The exterior of a hearing aid should be wiped regularly with a damp cloth. Alcohol should not be used as it can damage the device. The nursing assistant should place a washcloth in the sink before brushing dentures to protect them if dropped. Toothpaste is appropriate to clean dentures.