Nokea
The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching?
- A. I can expect the cord to turn black in a few days
- B. I should let the cord fall off by itself
- C. I’ll give my newborn sponge baths until the cord falls off
- D. I’ll secure the diaper over the cord to protect it
Correct Answer: D
Rationale: Securing the diaper over the cord traps moisture, increasing infection risk. The cord turning black, falling off naturally, and sponge baths are correct cord care practices.
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A culture is taken of a lesion suspected of being herpes. The nurse knows that the specimen:
- A. Should be packed on ice
- B. Should be kept warm
- C. Should be double bagged
- D. Requires no special handling
Correct Answer: A
Rationale: Herpes culture specimens should be packed on ice to preserve the virus for accurate laboratory testing.
All of the following tasks need to be done. Which one can the LPN/LVN safely delegate to the certified nursing assistant (CNA)?
- A. Tube feeding for a client with a nasogastric tube
- B. Routine vital signs for a group of clients
- C. Blood pressure monitoring for a client who is in congestive heart failure
- D. Wound care for a client with a stage III decubitus ulcer
Correct Answer: B
Rationale: Routine vital signs are within a CNA's scope of practice. Tube feeding, specialized blood pressure monitoring, and wound care require nursing judgment and skills.
The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?
- A. projection
- B. displacement
- C. rationalization
- D. reaction formation
Correct Answer: B
Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.
An 80-year-old woman has been hospitalized for three days with pneumonia. She is now able to sit in a chair for the first time. How should the nurse plan care for today?
- A. Give her a bed bath and make her bed. Get her up in the chair later.
- B. Get her up in the chair and have her give herself a bath while the nurse makes the bed.
- C. Give her a bed bath and come back later to get her up in the chair. Make the bed while she is up in the chair.
- D. Give her a bed bath and immediately get her up in the chair so the bed can be made.
Correct Answer: C
Rationale: A bed bath conserves energy, and later chair transfer allows bed-making, optimizing rest and mobility for a recovering pneumonia patient.
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).