Question

A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Initiate contact precautions.

Rationale :

♦️ Clostridium difficile infection requires strict contact precautions to prevent transmission via spores.

♦️ Contact precautions involve wearing gowns and gloves and proper hand hygiene with soap and water.

♦️ Airborne precautions like N95 respirators and HEPA filtration are not indicated for this infection.

♦️ Fresh flowers do not affect transmission and are not restricted in this case.

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Answer 2

Correct Answers:

“You can splint the incision with a pillow when changing positions.”

Rationale :

🟠 Splinting the incision site reduces pain by providing support and stability during movement.

🟠 This method minimizes tension on the surgical wound and helps ease discomfort.

🟠 Other methods like patterned breathing or limiting movement do not provide physical support.

🟠 Counterpressure to the back is unrelated to incision pain relief.

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Answer 3

Correct Answers:

"I will use frozen vegetables rather than canned."

Rationale :

🔶 Frozen vegetables generally have lower sodium content compared to canned versions.

🔶 Processed foods like ketchup, turkey sausage, and spaghetti sauce often contain high sodium.

🔶 Reducing sodium intake helps manage hypertension and reduces cardiovascular risks.

🔶 Teaching clients to read labels and choose low-sodium options is essential.

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Answer 4

Correct Answers:

Anaphylactic

Rationale :

🔷 The presence of urticaria and wheezing indicates a severe allergic reaction.

🔷 Anaphylactic transfusion reaction is an immediate, life-threatening hypersensitivity response.

🔷 Symptoms can include difficulty breathing, hypotension, and shock if not treated promptly.

🔷 This reaction requires emergency management with epinephrine and supportive care.

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Answer 5

Correct Answers:

Cover the wound with sterile, saline-soaked gauze.

Rationale :

🟢 Covering the wound with sterile, saline-soaked gauze helps prevent organ desiccation and contamination.

🟢 Applying direct pressure could damage protruding organs and worsen the injury.

🟢 Keeping the client’s knees in a flexed position reduces tension on the abdominal muscles.

🟢 Raising the head of the bed could increase intra-abdominal pressure and exacerbate the evisceration.

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Answer 6

Correct Answers:

Inject 15 units of air into the regular insulin vial.

Rationale :

🔴 After injecting air into the NPH vial, the nurse should inject air into the regular insulin vial next to maintain pressure balance.

🔴 This step prevents creating a vacuum and allows smooth withdrawal of insulin.

🔴 The rule “air into cloudy, air into clear” must be followed before drawing up insulin.

🔴 Placing the cap on the needle or withdrawing insulin before injecting air disrupts this process.

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Answer 7

Correct Answers:

"Let me show you how to swaddle and cuddle him, then you try."

Rationale :

🟣 This response promotes parental involvement and empowerment in newborn care.

🟣 Teaching swaddling and cuddling helps soothe both the baby and the parent.

🟣 It supports bonding and addresses the client’s feelings of inadequacy.

🟣 Taking the baby away without consent may increase maternal stress.

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Answer 8

Correct Answers:

Use written signs to assist the client with locating the bathroom.

Rationale :

🟤 Clients with Alzheimer’s disease benefit from environmental cues like written signs to maintain independence.

🟤 Limiting choices helps reduce confusion and anxiety.

🟤 A stimulating environment might exacerbate symptoms and agitation.

🟤 Confrontation typically worsens behavioral symptoms in dementia clients.

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Answer 9

Correct Answers:

"We will frequently check the top of his ears for sores."

Rationale :

⬦ Checking for pressure sores on the ears is important because the nasal cannula can cause skin breakdown.

⬦ Oxygen flow should be maintained at prescribed levels; turning it up to 10 L/min without order is unsafe.

⬦ Petroleum jelly is flammable and should not be used near oxygen equipment.

⬦ The nasal cannula should be removed only when necessary; eating does not require removal.

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Answer 10

Correct Answers:

Sublimation

Rationale :

💠 Sublimation is a defense mechanism where unacceptable impulses are transformed into socially acceptable actions.

💠 The adolescent is redirecting energy into productive activities like track and field.

💠 This helps the client cope with stress and reduces family conflict.

💠 Denial, regression, and repression do not involve this form of channeling emotions.

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QLexNursing

1 :
A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

3 :
A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

4 :
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

5 :
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

7 :
A nurse is caring for a client who recently gave birth to her first child. The newborn is crying, and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

8 :
A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

9 :
A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

10 :
A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?

QLexNursing

1 : A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

2 : A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

3 : A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

4 : A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

5 : A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

6 : A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

7 : A nurse is caring for a client who recently gave birth to her first child. The newborn is crying, and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

8 : A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

9 : A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

10 : A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?

1 :
A nurse is caring for a 2-year-old child who has Clostridium difficile. Which of the following actions should the nurse take?

2 :
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?

3 :
A nurse is reinforcing teaching about a low-sodium diet with a client who has hypertension. Which of the following statements by the client indicates an understanding of the instructions?

4 :
A nurse is monitoring a client who is receiving a blood transfusion. The nurse identifies that the client has urticaria and is wheezing. Which of the following types of transfusion reactions should the nurse suspect?

5 :
A nurse is caring for a client who is postoperative following abdominal surgery and has a wound evisceration. Which of the following actions should the nurse take?

6 :
A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?

7 :
A nurse is caring for a client who recently gave birth to her first child. The newborn is crying, and the client states, "I can't seem to do anything right. What should I do?" Which of the following responses should the nurse make?

8 :
A nurse is assisting with a community health program for caregivers of clients who have Alzheimer's disease. Which of the following information should the nurse include?

9 :
A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

10 :
A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?