Nokea
The nurse is talking about diaper changes with a client who is 48 hours postpartum. The client states, 'I cannot change my baby's diaper as well as you can. Will you change it for me?' Which of the following responses would be appropriate for the nurse to make?
- A. Changing your baby's diaper now is important for the bonding process.
- B. I will stay at your bedside and watch while you change your baby's diaper.
- C. It is more important for you to take care of yourself now, so I will change your baby's diaper.
- D. It is time that you change your baby's diaper because you will have to do it by yourself after discharge.
Correct Answer: B
Rationale: Supporting the client while they change the diaper builds confidence and promotes independence.
You may also like to solve these questions
Following a cholecystectomy, drainage from the client's T tube for the first 24 hours after the operation was 350 cc. What is the appropriate nursing action?
- A. Notify the physician.
- B. Raise the level of the drainage bag to decrease the rate of flow.
- C. Increase the IV flow rate to compensate for the loss.
- D. Continue to observe and measure drainage.
Correct Answer: D
Rationale: T-tube drainage of 300–500 mL in the first 24 hours post-cholecystectomy is expected as bile drains externally. Continuing to observe and measure is appropriate unless other signs of complications arise.
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
- A. Anorexia
- B. Seizures
- C. Diplopia
- D. Insomnia
Correct Answer: C
Rationale: Diplopia (double vision) is a common symptom during multiple sclerosis exacerbations, resulting from demyelination affecting the optic nerves or brainstem.
The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?
- A. Extreme fatigue
- B. Increased appetite
- C. Intense itching
- D. Constipation
Correct Answer: A
Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
- A. Allow the child to continue normal activities
- B. Schedule frequent rest periods
- C. Limit exposure to other children
- D. Restrict activities to inside the house
Correct Answer: A
Rationale: Allow the child to continue normal activities. Physical activity supports autonomy and mucus secretion in cystic fibrosis.
The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation