Nokea
The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up?
- A. I will contact the health care provider if bleeding does not stop with gentle pressure
- B. I should avoid using alcohol-based cleansing wipes during diaper changes
- C. I need to leave the device in place and allow it to fall off on its own
- D. I understand that yellow exudate on the area is a sign of infection
Correct Answer: D
Rationale: Yellow exudate is normal during circumcision healing, not a sign of infection, requiring further teaching. Contacting the provider for persistent bleeding, avoiding alcohol wipes, and leaving the device are correct.
You may also like to solve these questions
The nurse understands that which of these body substances are modes of transmission for hepatitis B? Select all that apply.
- A. Blood
- B. Feces
- C. Semen
- D. Urine
- E. Vaginal secretions
Correct Answer: A,C,E
Rationale: Hepatitis B is transmitted via blood, semen, and vaginal secretions. Feces and urine are not significant transmission modes.
A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The nurse should include which of the following in the priority teaching plan for the parents?
- A. Monitor respiratory rate
- B. Monitor intake and output every hour
- C. Assist the client to breathe into a paper bag
- D. Prepare to administer oxygen by mask
Correct Answer: C
Rationale: Assisting the client to breathe into a paper bag addresses hyperventilation caused by aspirin toxicity, which can lead to respiratory alkalosis in the initial stages.
The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?
- A. Section A
- B. Section B
- C. Section C
- D. Section D
Correct Answer: A
Rationale: Bubbling in the water seal chamber indicates an air leak from the lung or tubing. The suction control chamber bubbles with suction, and the collection chamber collects fluid, not air.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
The nurse on the mental health unit is leading a group session. Shortly after the session begins, a newly admitted client with schizophrenia stands and starts to leave the room. Which of the following actions should the nurse take?
- A. In a loud, firm voice, direct the client to come back to the room
- B. Gently grasp the client's arm and redirect the client back to the seat
- C. Reinforce the unit rules and importance of attending group sessions
- D. Remain silent and allow the client to leave the room with another staff member
Correct Answer: D
Rationale: Allowing the client to leave with another staff member respects their distress and ensures safety, avoiding confrontation. Loud commands, physical redirection, or rule enforcement may escalate agitation.