Question

A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

Answer 1

Correct Answers:

"You should bring the infant's favorite blanket to the hospital."

Rationale :

🔷 Bringing a familiar comfort item supports separation anxiety reduction and helps the infant feel secure in an unfamiliar environment.

🔷 Infants rely on consistent sensory comfort (smell, touch) to self-soothe during stress.

🔷 A favorite blanket can improve sleep and settling, which supports recovery and routine stability.

🔷 This is a developmentally appropriate intervention because infants cannot cognitively understand hospitalization.

🔷 Comfort objects support attachment needs and promote calmer coping during procedures and transitions.

“You should begin to manipulate the infant’s bedtime based on the hospital’s visiting hours.”

🔷 Altering routines often increases irritability and worsens coping because infants need predictable schedules.

🔷 The goal is to maintain normal routines, not reshape them around unit flow.

“Privacy is important to helping infant cope with hospital stay.”

🔷 Infants cope best with presence and reassurance, not privacy.

🔷 Privacy is more relevant to older children and adolescents who value modesty.

“You should read the child a story about hospitalization.”

🔷 Story preparation is more effective for preschool and school-age children who use imagination and explanations.

🔷 An 8-month-old infant does not process hospitalization concepts meaningfully.

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Answer 2

Correct Answers:

300

Rationale :

💎 Time interval:

♦️0330 → 0600 = 2 hours 30 minutes = 2.5 hours

💎 Formula:

♦️mL infused = rate × time

💎 Calculation:

♦️120 mL/hr × 2.5 hr

✔️ 300 mL

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Answer 3

Correct Answers:

Stop the transfusion.

Rationale :

⚫ Facial flushing and lower back pain during transfusion suggest a possible acute hemolytic reaction or severe reaction requiring immediate action.

⚫ The priority is to stop the transfusion to prevent further exposure to the triggering blood product.

⚫ Rapid action reduces risk of shock, DIC, hemoglobinuria, and renal failure.

⚫ After stopping, the nurse maintains IV access with 0.9% sodium chloride using new tubing per protocol.

⚫ Prompt recognition and stopping the transfusion is the most time-sensitive step for client safety.

Insert an indwelling urinary catheter.

⚫ Monitoring urine output is important later, but it does not stop the reaction source.

⚫ The immediate priority is halting the transfusion to prevent worsening.

Infuse 0.9% sodium chloride solution.

⚫ Normal saline is appropriate after stopping the transfusion to keep the line open.

⚫ Starting saline without stopping the blood delays the most critical intervention.

Send the blood and tubing to the laboratory.

⚫ Sending tubing is part of follow-up investigation, not the first action.

⚫ The priority is to stop the transfusion immediately before completing reporting steps.

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Answer 4

Correct Answers:

Papular, wheal-like lesions with white deposits on the hair shaft

Rationale :

🟣 Pediculosis capitis is commonly identified by nits (eggs) attached to the hair shaft, appearing as white/yellow deposits.

🟣 Itching and papular reactions occur due to sensitivity to lice saliva, producing wheal-like lesions.

🟣 Close contact sports and shared equipment increase spread, so headgear sharing is a key prevention point.

🟣 Nits adhere firmly and do not brush off easily, supporting clinical recognition.

🟣 Teaching emphasizes avoiding shared headgear and initiating treatment + contact cleaning to stop transmission.

Ringlike rashes with red, scaly borders over the entire scalp

🟣 This pattern is more consistent with tinea (fungal infection) than lice.

🟣 Lice present with nits and pruritus rather than ring-shaped scaling.

Red, hivelike papules and plaques with sharply circumscribed borders

🟣 This suggests urticaria/allergic reaction, not a parasitic infestation.

🟣 Pediculosis requires evidence of nits or live lice.

Patchy areas of alopecia with small vesicles and excoriated areas

🟣 Patchy alopecia is more consistent with tinea capitis or other dermatologic causes.

🟣 Lice typically cause itching and excoriations, but nits are the key distinguishing clue.

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Answer 5

Correct Answers:

Pruritus

Rationale :

🔷 Scabies causes intense pruritus, often worse at night, due to a hypersensitivity reaction to the mite, eggs, and feces.

🔷 Itching is the most prominent symptom and typically appears before the rash becomes widespread.

🔷 Scratching can lead to excoriations and secondary bacterial infection, making pruritus clinically significant.

🔷 Typical lesion patterns (papules/burrows) appear in areas like finger webs, wrists, waistline, and genital regions.

🔷 Teaching should stress treatment of close contacts and linen cleaning to stop reinfestation and relieve persistent itching.

Maceration

🔷 Maceration is usually caused by prolonged moisture exposure, not scabies infestation.

🔷 Scabies primarily produces itching and papular/burrow lesions rather than macerated skin.

Edema

🔷 Edema is not the hallmark manifestation of scabies.

🔷 Any swelling is typically secondary to inflammation or scratching, not the primary symptom.

Redness

🔷 Redness can occur, but it is not as defining as severe pruritus.

🔷 The key clinical clue remains nocturnal itching with characteristic distribution.

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Answer 6

Correct Answers:

Administration of naloxone

Rationale :

💎 A respiratory rate of 5/min with lethargy shortly after morphine indicates opioid-induced respiratory depression.

💎 The priority is to reverse life-threatening hypoventilation to prevent hypoxia and respiratory arrest.

💎 Naloxone is an opioid antagonist that rapidly reverses CNS and respiratory depression caused by opioids.

💎 Continuous monitoring is essential because naloxone may wear off before morphine, causing re-sedation.

💎 After stabilization, reassess pain management with safer dosing and close respiratory monitoring.

Administer flumazenil

💎 Flumazenil reverses benzodiazepines, not opioids.

💎 It will not correct morphine-related respiratory depression.

Assessment of the pain level

💎 Pain assessment is important, but airway and breathing take priority in a critical event.

💎 The client’s respiratory status must be stabilized first.

Observe for opioid tolerance

💎 This presentation reflects opioid toxicity, not tolerance.

💎 Observation delays reversal of a potentially fatal complication.

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Answer 7

Correct Answers:

Serous drainage from the top of the incision

Rationale :

⚫ A small amount of serous (clear/pale yellow) drainage can be a normal part of early wound healing.

⚫ Post-op day 3 is still within the inflammatory/early proliferative phase where mild serous drainage may occur.

⚫ Normal drainage should be minimal and not accompanied by foul odor, fever, or increasing pain.

⚫ The nurse should continue monitoring because a change to thick, colored drainage can signal infection.

⚫ Identifying expected serous drainage supports accurate assessment while maintaining vigilance for wound complications.

Redness and purulent drainage at the incision

⚫ Purulent drainage indicates infection due to pus formation.

⚫ This requires provider notification and wound evaluation.

Non-tender skin along the line of the incision

⚫ Mild tenderness is common early in healing, so complete non-tenderness is not the best expected indicator.

⚫ The more reliable normal sign is serous rather than purulent drainage.

Warm skin surrounding the surgical incision

⚫ Warmth may reflect inflammation, but increased warmth can also be a developing infection sign.

⚫ This is less clearly normal than serous drainage.

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Answer 8

Correct Answers:

"Notify your provider if you experience any changes in your hearing."

Rationale :

🟣 Vancomycin can cause ototoxicity, so hearing changes (ringing, muffled hearing) must be reported promptly.

🟣 Early reporting helps prevent progression to potentially irreversible hearing damage.

🟣 Vancomycin also carries risk for nephrotoxicity, making symptom reporting and monitoring essential.

🟣 Clients should take the medication exactly as prescribed to ensure infection is fully treated.

🟣 Teaching supports safety by focusing on early recognition of serious adverse effects like hearing changes.

“Discontinue the medication once your symptoms subside.”

🟣 Stopping early can cause incomplete treatment and relapse of infection.

🟣 Antibiotics must be taken for the full prescribed course.

“Expect your urine to turn pink or red while taking this medication.”

🟣 Pink/red urine is not an expected vancomycin effect.

🟣 Abnormal urine color warrants evaluation for bleeding or other causes.

“Decrease your fluid intake to 1000 mL per day.”

🟣 Adequate hydration supports kidney function, especially when nephrotoxic risk exists.

🟣 Fluid restriction is not routine teaching for vancomycin unless specifically ordered for another condition.

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Answer 9

Correct Answers:

Place the client supine with the knees flexed.

Rationale :

🟡 Placing the client supine with knees flexed reduces tension on the abdominal incision and helps prevent worsening separation.

🟡 This position decreases strain on the wound, limiting further dehiscence and potential evisceration.

🟡 The nurse’s priority is to protect the wound and minimize movement that increases intra-abdominal pressure.

🟡 After positioning, the nurse should notify the provider and prepare for additional interventions per protocol.

🟡 Proper positioning is an immediate, protective action that supports wound integrity and safety.

Offer the client a drink of water.

🟡 Oral fluids do not address the immediate wound emergency.

🟡 The client may need NPO status if surgery becomes necessary.

Cover the client’s wound with a clean towel.

🟡 The correct cover for wound separation is a sterile dressing, often moistened with sterile saline if evisceration occurs.

🟡 A towel is not a sterile, appropriate wound covering.

Apply an abdominal binder for support.

🟡 A binder may be ordered later, but it is not the first action when dehiscence is present.

🟡 Immediate priority is reducing tension by positioning and preventing worsening separation.

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Answer 10

Correct Answers:

The patient's albumin level is 2.4.

Rationale :

💎 A low albumin (2.4 g/dL) strongly suggests poor protein status/malnutrition, which is one of the biggest barriers to tissue repair.

💎 Protein is required for collagen formation, angiogenesis, immune function, and granulation, all essential for closing a stage 3 wound.

💎 When albumin is low, the patient is at higher risk for delayed healing, infection, and wound breakdown even if pressure is relieved.

💎 Nutritional optimization (adequate protein/calories, vitamins/minerals as needed) directly improves the body’s ability to rebuild damaged tissue.

💎 Because heels have limited soft tissue and poorer perfusion, nutrition status becomes even more critical for measurable healing progress.

The patient states his heels are very painful.

💎Pain is important to treat for comfort and mobility, but it does not correct the underlying tissue-repair needs.

💎Pain can occur with pressure injury and guides analgesia, not the primary healing capacity driver.

The patient has had the injuries for the last 6 months.

💎Chronicity suggests delayed healing, but it is a descriptor rather than a key correctable factor.

💎The priority is identifying what most impacts healing now, such as nutrition/pressure relief/perfusion.

The patient has several old incisions that have formed keloids.

💎Keloids reflect a scar tendency after certain wounds, not the main determinant for a pressure injury’s closure.

💎Pressure injuries heal primarily through granulation and epithelialization, and malnutrition is far more impactful.

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QLexNursing

1 :
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

2 :
At 0330, a nurse is caring for a client who is postoperative. The client's IV fluids are infusing at 120 mL/hr. How many mL of IV fluid should infuse by 0600? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

3 :
A nurse is monitoring a client receiving packed RBCs. The nurse notices facial flushing, and the client reports lower back pain. Which of the following actions is the priority for the nurse to take?

4 :
A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?

5 :
The primary clinical manifestation of scabies is:

7 :
The nurse assess a patient's surgical incision 3 days after surgery for signs of infection. Which finding by the nurse would indicate a normal finding?

8 :
A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

9 :
A nurse is caring for a client who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?

10 :
When admitting a patient with a stage 3 pressure injury on both heels, which information obtained by the nurse will have the most impact on wound healing?

QLexNursing

1 : A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

2 : At 0330, a nurse is caring for a client who is postoperative. The client's IV fluids are infusing at 120 mL/hr. How many mL of IV fluid should infuse by 0600? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

3 : A nurse is monitoring a client receiving packed RBCs. The nurse notices facial flushing, and the client reports lower back pain. Which of the following actions is the priority for the nurse to take?

4 : A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?

5 : The primary clinical manifestation of scabies is:

7 : The nurse assess a patient's surgical incision 3 days after surgery for signs of infection. Which finding by the nurse would indicate a normal finding?

8 : A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

9 : A nurse is caring for a client who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?

10 : When admitting a patient with a stage 3 pressure injury on both heels, which information obtained by the nurse will have the most impact on wound healing?

1 :
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?

2 :
At 0330, a nurse is caring for a client who is postoperative. The client's IV fluids are infusing at 120 mL/hr. How many mL of IV fluid should infuse by 0600? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

3 :
A nurse is monitoring a client receiving packed RBCs. The nurse notices facial flushing, and the client reports lower back pain. Which of the following actions is the priority for the nurse to take?

4 :
A teenaged male patient who wrestles in high school is examined by the nurse in the clinic. Which assessment finding would prompt the nurse to teach the patient about the importance of not sharing headgear to prevent the spread of pediculosis?

5 :
The primary clinical manifestation of scabies is:

7 :
The nurse assess a patient's surgical incision 3 days after surgery for signs of infection. Which finding by the nurse would indicate a normal finding?

8 :
A nurse is reinforcing teaching about vancomycin with a client who has an infection. Which of the following information should the nurse include in the teaching?

9 :
A nurse is caring for a client who has wound dehiscence one week postoperative. Which of the following actions should the nurse take?

10 :
When admitting a patient with a stage 3 pressure injury on both heels, which information obtained by the nurse will have the most impact on wound healing?