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The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
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The nurse is caring for a group of premature infants. Which action is most important in preventing healthcare-acquired infection?
- A. Performing frequent hand hygiene
- B. Disinfecting commonly touched surfaces
- C. Screening visitors for illness
- D. Administer prophylactic antibiotics
Correct Answer: A
Rationale: Frequent hand hygiene is the most effective measure to prevent healthcare-acquired infections in vulnerable populations like premature infants.
The nurse has attended a continuing education conference focused on reducing work-related injuries. Which statement by the nurse would require follow-up regarding actions helpful in reducing work-related injuries?
- A. Keeping back, neck, pelvis, and feet aligned helps maintain proper posture and reduces strain.
- B. I should position myself furthest away from the client (or object) being lifted.
- C. Flexing the knees and maintaining a broad base of support provides stability and helps distribute weight evenly.
- D. Encouraging the client to assist during repositioning or transfers promotes independence and reduces strain on the caregiver.
Correct Answer: B
Rationale: Positioning close to the client reduces strain during lifting. Other statements promote proper body mechanics.
The nursing instructor is supervising a nursing student feeding a client at risk for aspiration. Which action by the nursing student requires follow-up by the nursing instructor? Select all that apply.
- A. Instructs the client to tilt the head backward when drinking.
- B. Reminds the client to assume a chin-down position.
- C. Provides rest periods as needed during the meal.
- D. Positions the client upright for 30-60 minutes after a meal.
- E. Positions the head of the bed at a 45-degree angle during the meal.
Correct Answer: A
Rationale: Tilting the head backward increases aspiration risk. Chin-down position, rest periods, upright positioning, and 45-degree elevation are appropriate.
The nurse is planning a staff development conference about ways to prevent the transmission of the hepatitis C virus to healthcare workers. It would be appropriate for the nurse to cover which topic?
- A. How to obtain the HCV vaccine
- B. How to dispose of sharps safely
- C. How to dispose of urine and feces for those with HCV
- D. Isolation precautions for individuals with HCV
Correct Answer: B
Rationale: Safe sharps disposal prevents needlestick injuries, a primary transmission route for HCV. No vaccine exists, and urine/feces disposal or isolation are less relevant.
The nurse is caring for a client with a recently fractured left tibia who is grimacing and slightly diaphoretic. The nurse should initially
- A. Perform range of motion with the client's left leg.
- B. Obtain the client's temperature.
- C. Assess the client for pain.
- D. Administer prescribed oxycodone-acetaminophen.
Correct Answer: C
Rationale: Grimacing and diaphoresis suggest pain, which should be assessed first to guide interventions. Range of motion may worsen pain, temperature is secondary, and medication administration requires prior assessment.