Nokea
What is the most important consideration when teaching parents how to reduce risks in the home?
- A. Age and knowledge level of the parents
- B. Proximity to emergency services
- C. Number of children in the home
- D. Age of children in the home
Correct Answer: D
Rationale: Age of children in the home. Safety measures must be tailored to the developmental stage of the children.
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A two-day-old infant in the newborn nursery does not appear interested in taking formula from the mother or the nurse.
An appropriate nursing diagnosis is high risk for
- A. impaired swallowing.
- B. failure to thrive.
- C. fluid volume deficit.
- D. altered health maintenance.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) no information about swallowing provided with question (2) this is a medical diagnosis not a nursing diagnosis (3) correct-may become dehydrated (4) not specific for problem described
A student nurse obtaining an infant's vital signs.
Which of the following actions should the student nurse complete FIRST?
- A. Take an axillary temperature to minimize use of invasive procedures.
- B. Count respirations for 15 seconds and multiply the number by 4.
- C. Count respirations for a minute prior to arousing the infant.
- D. Use a stethoscope with a one-and-a-half-inch diaphragm to count the apical pulse.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate to use probe to take axillary temperature (2) should count for a full minute (3) correct-respirations should be counted for one full minute prior to arousing the infant with a temperature probe or stethoscope (4) after infant is stimulated, crying may interfere with accurate evaluation of respirations
The nurse is assisting a client with deep breathing and coughing exercises following abdominal surgery. What instruction is most appropriate for the nurse to give the client?
- A. Hold your breath for several seconds and then breathe out forcefully.
- B. Splint your incision while taking in deep breaths and coughing.
- C. Take deep breaths when you are moving in bed.
- D. Deep breathing exercises should be done when you are out of bed.
Correct Answer: B
Rationale: Splinting the incision reduces pain and supports effective deep breathing and coughing, preventing postoperative complications.
The nurse observes the certified nursing assistant doing all of the following. Which action needs correction?
- A. Changing the dressing of a client with an abdominal wound
- B. Asking a standing client to sit down while vital signs are taken
- C. Emptying a urine drainage bag from the tube at the bottom
- D. Changing water in the middle of a bed bath
Correct Answer: A
Rationale: Changing dressings requires nursing judgment and sterile technique, outside a CNA's scope. Other actions are within their role.
Which play activity is most appropriate for a 15-month-old with a cyanotic heart defect?
- A. Push-and-pull toy
- B. Mobile
- C. Shape sorter
- D. Pounding board
Correct Answer: B
Rationale: A mobile is a passive activity suitable for a 15-month-old with a cyanotic heart defect, as it avoids exertion, so B is correct. Push-and-pull toys , shape sorters , and pounding boards require more physical effort.