Nokea
The nurse is discussing child safety with the parents of a 12-month-old child who is just beginning to walk. Which statement by the parents indicates a need for further instruction?
- A. Our swimming pool is fenced in with a lock on the gate.'
- B. We have installed childproof gates at the top and bottom of our stairs.'
- C. We need to lower the mattress in our child's crib.'
- D. When we are unable to supervise, we can put our child in a mobile walker.'
Correct Answer: D
Rationale: Using a mobile walker is unsafe for a walking 12-month-old due to fall and injury risks, requiring further teaching. Fenced pools , stair gates , and lowered crib mattresses are appropriate safety measures.
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The physician has recommended that the client increase the amount of dietary iron. The nurse knows that the client understands the recommendation when the client selects which foods?
- A. Orange juice, scrambled eggs, and toast
- B. Hot dog and roll, French fries, and cola
- C. Roast beef, carrots, and rice
- D. Baked chicken, peas, and noodles
Correct Answer: C
Rationale: Roast beef is high in iron, suitable for increasing dietary iron. Other options lack significant iron sources.
The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply.
- A. Encourage the parents to leave the child's favorite stuffed animal
- B. Establish a daily schedule similar to the child's home routine
- C. Give the child time to calm down alone when visibly upset
- D. Provide frequent opportunities for play and activity
- E. Remove visual reminders of the parents from the room
Correct Answer: A,B,D
Rationale: To manage separation anxiety: a stuffed animal provides comfort, a familiar schedule offers stability, and play distracts and engages. Isolating the child may worsen anxiety, and removing parental reminders could increase distress.
The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply.
- A. Apply the patch when the ship starts moving and not before.'
- B. Dispose of the patch out of reach of children and pets.'
- C. Ensure that the old patch is removed before applying a new one.'
- D. Place the patch on a hairless, clean, dry area behind the ear.'
- E. Wash your hands with soap and water after handling the patch.'
Correct Answer: B,C,D,E
Rationale: Appropriate scopolamine instructions include safe disposal , removing old patches , correct placement , and hand washing . Applying the patch only when moving is incorrect, as it should be applied hours before travel.
The doctor has ordered the insertion of an NG tube to determine the extent of gastric bleeding in a client with a gastric ulcer. To facilitate the insertion of the NG tube, the nurse should:
- A. Place the NG tube in warm water prior to insertion.
- B. Place the client in a supine position.
- C. Ask the client to swallow as the tube is advanced.
- D. Ask the client to hyper-extend his neck as the nurse begins to insert the tube.
Correct Answer: C
Rationale: Asking the client to swallow helps guide the NG tube into the esophagus and stomach, facilitating insertion.
The nurse is providing home care for a client who is visually impaired. What safety precaution is most appropriate for this client?
- A. Remove scatter rugs.
- B. Have hand rails in the bathroom.
- C. Have side rails up whenever the client is in bed.
- D. Have a bell to call for help.
Correct Answer: A
Rationale: Removing scatter rugs prevents tripping, the most effective safety measure for a visually impaired client at home.