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The nurse is teaching a parenting class on infant car seat safety. Which statements should the nurse include? Select all that apply.
- A. Place the car seat rear-facing in the back seat and at 90 degrees.
- B. The car seat straps should fit snugly over the shoulders.
- C. Infants should ride in a car seat, rear-facing, in the back seat, until six months.
- D. Rolled blankets may be needed between the crotch and legs to prevent slouching.
- E. You may add padding underneath the infant to increase their comfort.
Correct Answer: B,D
Rationale: Snug straps and rolled blankets for positioning are correct. Rear-facing should be until at least 2 years, not 90 degrees, and padding underneath is unsafe.
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The nurse supervises unlicensed assistive personnel (UAP) assist a bed-bound client with oral hygiene. Which action by the UAP requires follow-up? Select all that apply.
- A. Raises the head of the bed (HOB) to 15 degrees
- B. Positions the toothbrush bristles at a 45-degree angle to the gum line
- C. A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits. None Regular The correct answer is A. Rationale: Pulse 5 is bradycardic for a child.
- D. Removes the towel and places it in a biohazard bag
- E. Applies moisturizing lubricant to the lips after brushing and rinsing
Correct Answer: A,D
Rationale: These actions by the UAP require follow-up. The head of the bed should ideally be elevated to between 30-45 degrees to facilitate effective oral hygiene and reduce the risk of aspiration. A lower angle may make it more difficult for the client to swallow properly and increase the risk of choking. Placing a towel used for oral hygiene in a biohazard bag is unnecessary unless it is saturated with blood or other potentially infectious materials. The towel used to protect the client's clothing during oral hygiene is typically considered regular linen and should be placed in a linen bag for laundering. Using a biohazard bag for non-contaminated items increases waste and may lead to confusion in waste management procedures.
The nurse is developing a care plan for a child scheduled to be admitted to the oncology unit to receive treatment for leukemia. To facilitate effective transition to the hospitalized environment, the nurse should recommend that the parents
- A. Purchase new toys for the child.
- B. Allow flexibility in the daily routine, so it changes often.
- C. Bring in the child's favorite toys from home.
- D. Limit parental visitation to specific times.
Correct Answer: C
Rationale: Familiar toys provide comfort, easing the hospital transition. New toys lack familiarity, flexible routines disrupt stability, and limited visitation increases anxiety.
The nurse is discussing mass casualties with a group of nursing students. Which statement by the student would indicate effective understanding? Select all that apply.
- A. Mass casualties are events that overwhelm local medical capabilities.
- B. When a mass casualty occurs, there is a need to increase the staff at the hospital.
- C. Many local agencies will collaborate to handle a mass casualty situation.
- D. An example of a mass casualty event is a fight between visitors in the intensive care unit.
- E. Staff preferences for client assignments should prioritize over client needs.
Correct Answer: A,B,C
Rationale: Mass casualties overwhelm resources, require more staff, and involve multi-agency collaboration. A visitor fight is not a mass casualty, and client needs take priority.
The nurse is preparing to insert a nasogastric tube (NGT). Which action should the nurse take?
- A. Rinse the tube with warm, soapy water
- B. Perform hand hygiene
- C. Don sterile gloves
- D. Obtain a computed tomography (CT) scan to verify placement
Correct Answer: B
Rationale: Hand hygiene is essential before NGT insertion to prevent infection. Rinsing with soapy water is incorrect, clean gloves suffice, and CT is not used for verification.
The nurse observes a client perform isometric exercises. It would indicate effective understanding if the client
- A. Exercises both extremities simultaneously.
- B. Knows their heart rate should be monitored while exercising.
- C. Practices forced resistance against stable objects.
- D. Swings their limbs through the full range of motion.
Correct Answer: C
Rationale: Isometric exercises involve static muscle contraction against resistance, like pushing against a stable object. Simultaneous exercise, heart rate monitoring, and full range of motion are not specific to isometrics.