Question

A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching?

Answer 1

Correct Answers:

"I will apply petroleum jelly to the penis with each diaper change."

Rationale :

🟢 Applying petroleum jelly creates a protective barrier, prevents the diaper from sticking to the circumcision site, and promotes healing.

🟢 This practice helps reduce pain and discomfort during diaper changes and minimizes trauma to the healing tissue.

🟢 Petroleum jelly keeps the area moist, which supports proper healing and reduces the risk of scab formation or bleeding.

🟢 The parent should not remove yellow exudate (it’s part of normal healing), should avoid snug diapers (can cause pressure), and should use only warm water (not soap) to clean until the site is healed.

🟢 Consistent use of petroleum jelly is a key recommendation from pediatric guidelines for post-circumcision care.

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Answer 2

Correct Answers:

Begin by testing the client while they are wearing glass

Rationale :

🟣 Visual acuity testing should be performed with corrective lenses in place to assess the client's best corrected vision, which is most relevant to daily function.

🟣 This approach helps the nurse evaluate whether the client's current prescription is adequate or if changes may be needed.

🟣 Testing without glasses is only necessary if the provider specifically wants uncorrected vision results.

🟣 The client should stand 6 meters (20 feet) from the chart, not 3 meters.

🟣 The test is done one eye at a time (with the other covered), not with both eyes open.

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Answer 3

Correct Answers:

Raise the head of the client's bed to 30 degrees.

Rationale :

🟢 Raising the head of the bed to 30 degrees helps prevent facial discoloration and pooling of blood (livor mortis) in the face, which maintains a more natural appearance for family viewing.

🟢 This positioning also helps prevent fluids from draining into the facial area, making the client appear more comfortable and dignified.

🟢 The nurse should cleanse the body with clean gloves (not sterile gloves), and generally inserts dentures (if present) to maintain face shape—not removes them.

🟢 The eyes are gently closed by hand (not taped) to achieve a peaceful expression.

🟢 These steps ensure the client is presented respectfully and comfortingly for the family.

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Answer 4

Correct Answers:

Working phase

Rationale :

🟣 The working phase of the therapeutic relationship is where the nurse and client collaborate to set goals, develop problem-solving skills, and actively work toward achieving health-related outcomes.

🟣 During this phase, the nurse provides education, supports coping mechanisms, and helps the client practice and refine new behaviors.

🟣 This is the main phase for implementing interventions and making progress toward identified goals, including managing chronic illness challenges.

🟣 The orientation phase focuses on establishing trust and identifying problems, while the termination phase deals with summarizing achievements and ending the relationship.

🟣 The reinteraction phase occurs before meeting the client and involves preparation and planning.

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Answer 5

Correct Answers:

Graham crackers

Rationale :

🟢 Graham crackers are soft, easy to chew, and do not pose a choking hazard, making them an appropriate snack choice for toddlers.

🟢 Foods for toddlers should be easy to handle, dissolve easily, and be unlikely to cause airway obstruction.

🟢 Marshmallows, almonds, and raw carrot sticks are all choking hazards for toddlers due to their shape, size, and texture.

🟢 Toddlers have limited chewing ability and can easily choke on small, hard, or sticky foods.

🟢 The nurse’s guidance should always emphasize safety and developmental appropriateness in food choices for this age group.

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Answer 6

Correct Answers:

"I will apply a heating pad to make my hands feel better."

Rationale :

🟣 Applying a heating pad is an effective, non-pharmacological intervention for relieving pain, stiffness, and swelling associated with osteoarthritis.

🟣 Heat therapy increases blood flow, reduces muscle tension, and can help improve joint mobility, especially in the hands.

🟣 The client should avoid exercising inflamed joints excessively, as this can worsen pain and swelling.

🟣 Aspirin should always be taken with food or milk to reduce GI irritation.

🟣 Sleeping on a firm (not soft) mattress is recommended for proper body alignment and joint support.

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Answer 7

Correct Answers:

Insert the rectal tube in the direction of the client's umbilicus.

Rationale :

🟢 Inserting the rectal tube toward the umbilicus follows the natural anatomical direction of the rectum and colon, minimizing risk of trauma or perforation.

🟢 Proper technique helps ensure the enema is administered safely and effectively, reducing discomfort and the chance of injury.

🟢 The client should never be instructed to bear down during tube insertion, as this can cause strain and possible injury.

🟢 Only one enema should be given at a time unless a provider orders otherwise, to prevent fluid and electrolyte imbalances.

🟢 The left Sims' position (not right) is the recommended position for enema administration, as it allows the solution to flow downward into the sigmoid colon.

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Answer 8

Correct Answers:

Chronic constipation

Rationale :

🟢 Chronic constipation is a major risk factor for hemorrhoids, as straining during hard bowel movements increases pressure in the rectal veins, leading to swelling and formation of hemorrhoids.

🟢 Repeated episodes of constipation cause chronic irritation and stretching of anal and rectal tissues.

🟢 Clients with hemorrhoids often report a history of infrequent, hard stools and difficulty with evacuation.

🟢 While occasional changes in bowel habits may occur, frequent stools, excessive flatulence, or fecal incontinence are less directly linked to hemorrhoids.

🟢 Preventing constipation through diet, hydration, and activity is a key part of managing and preventing hemorrhoids.

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Answer 9

Correct Answers:

Perform oral care every 2 hours

Rationale :

🟢 Performing oral care every 2 hours is essential for clients on mechanical ventilation to prevent ventilator-associated pneumonia (VAP) by reducing bacterial colonization in the mouth and oropharynx.

🟢 Frequent oral care helps maintain oral mucosa integrity, reduces the risk of infection, and promotes comfort.

🟢 The endotracheal tube should not be routinely repositioned by time intervals, but per policy and clinical need.

🟢 The client should be positioned with the head of the bed elevated (not supine) to reduce aspiration risk.

🟢 Vital signs for ventilated clients are monitored more frequently than every 8 hours to quickly detect changes in respiratory or cardiovascular status.

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Answer 10

Correct Answers:

Inform the family that the client has the right not to take the medication.

Rationale :

🟢 Clients have the right to refuse medication if they are competent and not a danger to themselves or others, and this autonomy must be respected in all care settings.

🟢 Concealing medication in food without the client's knowledge is unethical and violates client rights and informed consent.

🟢 The nurse should educate the family about the importance of respecting the client's decisions, even if the family disagrees.

🟢 Covert medication administration is only permissible in rare situations and requires a legal and ethical process with provider and ethics committee involvement.

🟢 The nurse’s role is to advocate for the client's rights and ensure care is delivered ethically and lawfully.

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QLexNursing

1 :
A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching?

2 :
A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

3 :
A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem-solving skills?

5 :
A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include?

6 :
A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain, swelling, and stiﬀness. Which of the following client statements indicates understanding of the teaching?

7 :
A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

8 :
A nurse is collecting health history data from a client who has hemorrhoids. Which of the following findings should the nurse expect?

9 :
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

QLexNursing

1 : A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching?

2 : A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

3 : A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

4 : A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem-solving skills?

5 : A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include?

6 : A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain, swelling, and stiﬀness. Which of the following client statements indicates understanding of the teaching?

7 : A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

8 : A nurse is collecting health history data from a client who has hemorrhoids. Which of the following findings should the nurse expect?

9 : A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?

10 : A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?

1 :
A nurse is reinforcing teaching with the parents of a newborn who had a circumcision. Which of the following client statements indicates understanding of the teaching?

2 :
A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

3 :
A nurse is providing postmortem care for a client prior to the family viewing the body. Which of the following actions should the nurse take?

4 :
A nurse is caring for a client who has a chronic illness. In which phase of the therapeutic relationship should the nurse help the client develop problem-solving skills?

5 :
A nurse is reinforcing teaching with a parent about appropriate snacks for a toddler. Which of the following foods should the nurse include?

6 :
A nurse is reinforcing teaching with a client diagnosed with osteoarthritis who reports joint pain, swelling, and stiﬀness. Which of the following client statements indicates understanding of the teaching?

7 :
A nurse is reinforcing discharge teaching with an older adult client's family about safety precautions when administering a tap water enema to the client. Which of the following should the nurse include in the instructions?

8 :
A nurse is collecting health history data from a client who has hemorrhoids. Which of the following findings should the nurse expect?

9 :
A nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who has major depressive disorder and is refusing their medication. The client's family suggests placing the client's medication in their food. Which of the following actions should the nurse take?