Question

A nurse is assisting with a community health education program about childhood communicable diseases. Which of the following information should the nurse include in the presentation?

Answer 1

Correct Answers:

Isolate children who have varicella until the vesicles have formed crusts.

Rationale :

💥Varicella (chickenpox) is a viral disease caused by the varicella-zoster virus.

💥Children are contagious 1–2 days before rash onset until all lesions have crusted over, which usually takes about 5–7 days.

💥Isolation during this period is essential to prevent transmission to other children, especially those who are immunocompromised or unvaccinated.

💥The nurse should stress that returning to school or daycare is safe only once all blisters are crusted.

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Answer 2

Correct Answers:

Soiled linens are placed on the floor.

Rationale :

✦ Soiled linens contain microorganisms that can easily contaminate the environment and become a direct source of infection for an immunocompromised client, whose immune defenses are already weak.

✦ Placing them on the floor increases microbial spread through contact, air circulation, and possible transfer to other surfaces.

✦ Immunocompromised clients are at higher risk of hospital-acquired infections, so infection-control practices like handling linens properly are essential.

✦ Standard precautions require soiled linens to be placed immediately in a designated laundry bag to prevent contamination and protect vulnerable patients.

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Answer 3

Correct Answers:

Fever

Rationale :

💎Pertussis (whooping cough) is a highly contagious respiratory infection caused by Bordetella pertussis.

💎 Early manifestations often include low-grade fever, mild cough, and nasal congestion before progressing to the characteristic paroxysmal "whooping" cough with post-tussive vomiting.

💎 The other listed signs are linked to different illnesses: Koplik spots → measles, facial erythema → fifth disease (erythema infectiosum), and beefy, red tongue → scarlet fever.

💎 Recognizing fever and cough as initial findings is important for early detection and isolation to prevent spread.

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Answer 4

Correct Answers:

A peer-reviewed journal article

Rationale :

🔷Peer-reviewed journal articles are considered the gold standard for evidence-based practice because they are reviewed by experts, rely on current research, and provide reliable, validated data.

🔷 Vendors may have bias since their goal is to promote products rather than provide objective evidence.

🔷 First-hand experience is valuable but anecdotal, lacking scientific rigor and generalizability.

🔷 Blogs may provide insights but are not considered credible scholarly sources.

🔷 For wound care updates, evidence-based information must be drawn from systematic research and clinical trials, which peer-reviewed journals provide.

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Answer 5

Correct Answers:

Tell the APS to stop the conversation.

Rationale :

✅Client information is confidential and protected under HIPAA regulations. Discussing a client in a public area such as the nurses’ station is a breach of confidentiality.

✅ The nurse’s immediate responsibility is to stop the violation to protect the client’s privacy and prevent further disclosure.

✅ Informing the client is not appropriate, as it does not address the breach in real time.

✅ Submitting an incident report may be necessary later if required by facility policy, but the priority action is to stop the breach immediately.

✅ Documentation in the client’s chart is not appropriate since this event is not part of the client’s care.

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Answer 6

Correct Answers:

Wear cotton underwear

Rationale :

🔹Wearing cotton underwear helps reduce moisture retention, allowing better air circulation and lowering bacterial growth, which decreases the risk of recurrent urinary tract infections (UTIs).

🔹 Clients with UTIs should also be encouraged to complete the full course of antibiotics, not stop when symptoms improve, to prevent resistance—though the option here is worded incorrectly.

🔹 Orange juice is not routinely recommended, as acidic drinks may irritate the bladder.

🔹 Fluid restriction is inappropriate; instead, clients are usually encouraged to increase fluid intake to help flush bacteria from the urinary tract.

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Answer 7

Correct Answers:

A client who has a urinary output of 30 mL in the past hour

Rationale :

🔷Licensed practical nurses (LPNs) can care for stable clients and those with predictable outcomes, such as monitoring urinary output and reporting abnormal findings. A urine output of 30 mL/hr is at the lower limit of normal, and while it requires continued monitoring, it does not require immediate critical care or new assessments.

🔷 The client with RR of 10/min is unstable and needs immediate RN intervention.

🔷 A new admission assessment must be performed by an RN, as it requires comprehensive data collection and clinical judgment.

🔷 New diagnosis and teaching (meal planning for diabetes) also fall within the RN’s role, as client education and development of care plans are not delegated to LPNs.

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Answer 8

Correct Answers:

Colostrum provides many important antibodies that the newborn lacks.

Rationale :

💠Colostrum is the thick, yellowish, early breast milk produced in the first few days after birth.

💠 It is rich in immunoglobulins (especially IgA), leukocytes, and proteins that help protect the newborn against infection by boosting immature immune defenses.

💠 Colostrum also has a mild laxative effect, aiding in meconium passage and reducing bilirubin buildup, but its primary importance lies in providing passive immunity.

💠 Iron, vitamin K, and diuretic properties are not its main benefits—vitamin K, for instance, is given by injection at birth, not supplied in sufficient amounts through colostrum.

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Answer 9

Correct Answers:

Crackles heard in the lungs

Rationale :

⭐Crackles in the lungs indicate pulmonary congestion from excess fluid, a classic sign of fluid overload in clients receiving enteral or IV fluids.

⭐ Enteral tube feedings can contribute to fluid retention if free water flushes or formulas exceed the client’s tolerance, especially in those with compromised cardiac or renal function.

⭐ Other manifestations of fluid overload may include edema, bounding pulses, hypertension, jugular vein distention, and sudden weight gain.

⭐ Decreased skin turgor, weight loss, and hypotension are consistent with fluid volume deficit, not overload.

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Answer 10

Correct Answers:

Ensure that the client gave informed consent.

Rationale :

🔶An esophagogastroduodenoscopy (EGD) is an invasive diagnostic procedure requiring informed consent prior to sedation and insertion of the endoscope.

🔶 The nurse’s priority responsibility before the procedure is to verify that the client understands the risks, benefits, and purpose, and that the signed consent form is in the chart.

🔶 Oral contrast is used for imaging studies such as a barium swallow or CT scan, not for an EGD.

🔶 The client must be NPO, not with a full bladder.

🔶 While the procedure usually lasts about 20–30 minutes, the key legal and ethical step is confirming informed consent.

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PN NJ Eve OB-Peds Exam 2...2025 - Teterboro Eve 2

No.

1 :
A nurse is assisting with a community health education program about childhood communicable diseases. Which of the following information should the nurse include in the presentation?

2 :
A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

3 :
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

4 :
A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

5 :
A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

6 :
A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

7 :
A charge nurse is making assignments for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

8 :
A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. Why is colostrum so important for my baby?
Which of the following responses should the nurse make?

9 :
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

10 :
A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

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PN NJ Eve OB-Peds Exam 2...2025 - Teterboro Eve 2

No.

1 : A nurse is assisting with a community health education program about childhood communicable diseases. Which of the following information should the nurse include in the presentation?

2 : A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

3 : A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

4 : A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

5 : A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

6 : A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

7 : A charge nurse is making assignments for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

8 : A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. Why is colostrum so important for my baby?Which of the following responses should the nurse make?

9 : A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

10 : A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?

1 :
A nurse is assisting with a community health education program about childhood communicable diseases. Which of the following information should the nurse include in the presentation?

2 :
A nurse is providing care to a client who is immunocompromised. Which of the following should the nurse identify as a possible source of infection?

3 :
A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

4 :
A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff. Which of the following sources should the nurse identify as providing the best evidence-based information?

5 :
A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

6 :
A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

7 :
A charge nurse is making assignments for a group of clients. Which of the following clients should the nurse assign to a licensed practical nurse?

8 :
A nurse is reinforcing teaching about colostrum with a new mother who is breastfeeding. The mother asks. Why is colostrum so important for my baby?
Which of the following responses should the nurse make?

9 :
A nurse is collecting data for a client who is receiving enteral tube feedings. The nurse should identify that which of the following findings is a manifestation of fluid overload?

10 :
A nurse is caring for a client who has peptic ulcer disease and is scheduled to undergo an esophagogastroduodenoscopy. Which of the following actions should the nurse take prior to the procedure?