What should be included in teaching a client undergoing a bilateral tubal ligation?
- A. The surgical procedure is easily reversible.
- B. Menstruation usually ceases after the procedure.
- C. Libido should remain the same after the procedure.
- D. The incision will be made endocervically.
Correct Answer: C
Rationale: Tubal ligation does not affect libido.
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The nurse assures the breastfeeding mother that she will know that her infant is getting an adequate supply of breast milk if the infant gains weight and:
- A. Rarely sucks on a pacifier.
- B. Ha several hard stools daily
- C. Voids 6 or more times a day
- D. Awakens to feed every 4 hours
Correct Answer: C
Rationale: Frequent voiding indicates adequate intake.
A nurse is conducting an orientation program for a group of newly hired nurses. As part of the program, the nurse is reviewing the issue of informed consent. The nurse determines that the teaching was effective when the group identifies which situation as a violation of informed consent?
- A. Performing a procedure on a 15-year-old without parental consent
- B. Serving as a witness to the signature process on an operative permit
- C. Asking whether the client understands what she is signing following receiving education
- D. Getting verbal consent over the phone for an emergency procedure from the spouse of a unconscious woman
Correct Answer: A
Rationale: In most states, only clients over the age of 18 can legally provide consent for health care. Serving as a witness to the signature process, asking whether the client understands what she is signing, and getting verbal consent over the phone for emergency procedures are all key to informed consent and are not violations.
A 2-week-old neonate is admitted to the hospital with a diagnosis of possible sepsis. The neonate weighs 3.2 kg, The health care provider prescribes the following orders for the neonate and signs the order sheet. Which order would the nurse question? Progress Notes: 12/01/22- 10am
- A. Acetaminophen (Tylenol) 10mg/kg per rectum every 4-6 hours prn for pain
- B. Ampicillin 200mg/kg IV every 6 hours in D5.45 NSSIV @ 125ml/hr.
- C. Mom may breastfeed ad lib
- D. Draw blood cultures x 3 in A.M.
Correct Answer: B
Rationale: Ampicillin dosage exceeds recommended levels for neonates.
The parents of a male newborn ask the nurse whether they should have their son circumcised. The nurse ‘s most appropriate response would be:
- A. "It would be a good idea because circumcision is known to prevent penile cancer."
- B. "That's something you both will have to decide after you discuss it thoroughly with your doctor."
- C. "The Academy of Pediatrics recommends that circumcision not be done routinely because of the risks associated with the procedure."
- D. "I'm sure you have discussed this with your doctor, but let's review the benefits and risks of circumcision'.
Correct Answer: B
Rationale: The most appropriate response for the nurse in this situation is to encourage open discussion between the parents and the doctor regarding the decision to circumcise their son. This allows the parents to make an informed decision based on their beliefs, values, and medical advice provided by the healthcare provider. It is important for parents to have all the necessary information and support to make the best decision for their child's well-being. The decision to circumcise is a personal one and should be made after careful consideration and consultation with a healthcare professional.
The nurse is monitoring a client receiving magnesium sulfate for preeclampsia. What finding indicates the need to discontinue the infusion?
- A. Urine output of 50 mL/hour.
- B. Respiratory rate of 10 breaths per minute.
- C. Blood pressure of 140/90 mmHg.
- D. Deep tendon reflexes +3.
Correct Answer: B
Rationale: A respiratory rate below 12 breaths per minute is a sign of magnesium sulfate toxicity, requiring immediate discontinuation.