The nurse is reinforcing teaching about infant safety to a class of expectant parents. Which statement by a participant indicates a need for further instruction?
- A. I will allow my baby to sleep with a pacifier.
- B. I will dress my baby in a sleeping sack to prevent my baby from getting cold.
- C. I will make sure there is a firm mattress in the crib.
- D. I will only place one teddy bear in the crib to comfort my baby
Correct Answer: D
Rationale: Placing a teddy bear in the crib (D) increases suffocation risk, requiring further teaching. Pacifiers (A), sleep sacks (B), and firm mattresses (C) are safe.
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When rendering aid to a victim who appears to be choking, the nurse's first action should be to:
- A. Administer a blow to the back.
- B. Ask the client whether she can speak.
- C. Administer a chest thrust.
- D. Establish an airway.
Correct Answer: B
Rationale: Asking if the victim can speak assesses airway obstruction severity. Back blows or chest thrusts follow if needed, and establishing an airway is not the first step.
The nurse is planning care for an 11-year-old child with attention deficit hyperactivity disorder who is hospitalized for surgical treatment of a fractured femur. What is the priority nursing action?
- A. Create a structured and consistent environment with a daily schedule
- B. Give the child a written schedule of activities
- C. Provide a verbal explanation of what to expect during hospitalization
- D. Restrict visitors while the child is hospitalized
Correct Answer: A
Rationale: A structured environment (A) supports ADHD management by reducing overstimulation and providing predictability, critical for a hospitalized child. Written schedules (B) and verbal explanations (C) are secondary, and restricting visitors (D) is unnecessary.
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
- A. dyspnea
- B. heart murmur
- C. macular rash
- D. Hemorrhage
Correct Answer: B
Rationale: Large, soft, rapidly developing vegetations attach to the heart valves. They have a tendency to break off, causing emboli and leaving ulcerations on the valve leaflets. These emboli produce findings of cardiac murmur, fever, anorexia, malaise and neurologic sequelae of emboli.
The practical nurse (PN) is assisting with a client who is undergoing labor induction with misoprostol. The PN notes late decelerations and minimal variability on the fetal heart rate monitor. After notifying the registered nurse, what should the PN do first?
- A. Administer 10 L/min oxygen by face mask
- B. Examine the perineum to check for bloody show
- C. Palpate the client's abdomen
- D. Reposition the client to a side-lying position
Correct Answer: D
Rationale: Repositioning to a side-lying position (D) improves placental perfusion, addressing late decelerations. Oxygen (A) may follow, but repositioning is first. Perineal exam (B) and palpation (C) are less urgent.
The nurse is caring for a depressed client with a new prescription for a selective serotonin reuptake inhibitor (SSRI) antidepressant. In reviewing the admission history and physical, which of the following should prompt questions about the safety of this medication?
- A. History of obesity
- B. Prescribed use of a monoamine oxidase (MAO) inhibitor
- C. Diagnosis of vascular disease
- D. Takes antacids frequently
Correct Answer: B
Rationale: SSRIs should not be taken concurrently with MAO inhibitors because serious, life-threatening reactions may occur with this combination of drugs.