Nokea
Which action by the healthcare worker indicates a need for further teaching?
- A. The nursing assistant ambulates the elderly client using a gait belt.
- B. The nurse wears goggles while performing a venipuncture.
- C. The nurse washes his hands after changing a dressing.
- D. The nurse wears gloves to monitor the IV infusion rate.
Correct Answer: D
Rationale: Wearing gloves to monitor an IV infusion rate is unnecessary unless contact with bodily fluids is anticipated indicating a need for further teaching on standard precautions. The other actions are appropriate safety measures.
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A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?
- A. Keep the umbilical area moist with Vaseline until the stump falls off.
- B. Keep the umbilical area covered at all times with the diaper.
- C. Clean the umbilical cord with alcohol at each diaper change.
- D. Clean the umbilical cord daily with soap and water during the bath.
Correct Answer: C
Rationale: The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
The physician has ordered a low-residue diet for a client with Crohn's disease. Which food is not permitted in a low-residue diet?
- A. Mashed potatoes
- B. Smooth peanut butter
- C. Fried fish
- D. Rice
Correct Answer: C
Rationale: A low-residue diet minimizes fiber and irritating foods; fried fish is high in fat and can irritate the gut, making it unsuitable for Crohn's disease.
Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
- A. Broiled fish with rice
- B. Bran flakes with fresh peaches
- C. Lasagna with garlic bread
- D. Cauliflower and lettuce salad
Correct Answer: A
Rationale: Broiled fish and rice are excellent protein sources, aiding in restoring albumin levels for tissue repair. The other options are lower in protein.
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.
A client with a history of a brain tumor is receiving Decadron (dexamethasone). The nurse should monitor the client for:
- A. Weight gain
- B. Hypotension
- C. Hypoglycemia
- D. Hair loss
Correct Answer: A
Rationale: Dexamethasone, a corticosteroid, causes weight gain due to fluid retention and increased appetite. Hypotension, hypoglycemia, and hair loss are not typical side effects.