Question

A nurse is verifying how a client who is postpartum will use a car seat for her newborn. Which of the following statements should the nurse identify as an indication that the client understands the safe use of a car seat?

Answer 1

Correct Answers:

"I'll place him in the back seat facing the back of the front seat."

Rationale :

🔹 The back seat is the safest location for infants because it protects them from injury caused by front passenger airbags, which can deploy with deadly force.

🔹 A rear-facing position supports the infant’s head, neck, and spine by distributing crash forces evenly along the entire back.

🔹 Newborns have weak cervical muscles and an incompletely ossified spine, making rear-facing positioning essential for spinal protection.

🔹 National safety guidelines recommend infants remain rear-facing until at least age 2 years or until reaching manufacturer weight/height limits.

🔹 Proper positioning significantly reduces the risk of severe traumatic brain injury and cervical spine injury in collisions.

"I'll place him in the front seat facing the back of the car."

🔹 The front seat is unsafe for infants because airbag deployment can cause fatal head and neck injuries.

🔹 Even if rear-facing, placing the seat in front exposes the newborn to high-impact crash forces due to proximity to the dashboard.

"I'll place him in the front seat facing the front of the car."

🔹 A forward-facing position is unsafe for newborns because it places excessive stress on the cervical spine during sudden deceleration.

🔹 The front seat further increases risk due to airbag impact and higher injury rates in frontal collisions.

"I'll place him in the back seat facing the back seat."

🔹 This describes a forward-facing position, which is inappropriate for newborns who lack neck strength.

🔹 Forward-facing seats do not properly distribute crash forces, increasing the risk of spinal cord and head injury.

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Answer 2

Correct Answers:

"Tighten a muscle group, then release the tension and move to the next one."

Rationale :

🔹 Progressive muscle relaxation (PMR) is a behavioral technique that involves systematically tightening and then relaxing specific muscle groups.

🔹 This method helps the client become aware of the difference between muscle tension and relaxation, which is essential in managing generalized anxiety disorder (GAD).

🔹 Anxiety commonly causes chronic muscle tension, and intentional release reduces sympathetic nervous system activation.

🔹 PMR promotes activation of the parasympathetic nervous system, lowering heart rate, blood pressure, and overall physiologic stress.

🔹 Regular practice improves self-regulation and coping skills, making it an evidence-based intervention for stress reduction.

"Picture taking the stress you feel and pushing it down and out of your feet."

🔹 This describes a visualization technique rather than progressive muscle relaxation.

🔹 PMR specifically involves physical tightening and releasing of muscles, not imagery alone. "Think about a positive outcome to a stressful situation."

🔹 This reflects cognitive reframing, a cognitive-behavioral strategy.

🔹 Progressive relaxation focuses on physical muscle tension reduction, not thought restructuring. "Focus on a pleasant memory and express your emotions in writing."

🔹 This represents journaling or guided imagery techniques.

🔹 Progressive relaxation requires active muscle engagement, not emotional expression exercises.

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Answer 3

Correct Answers:

Bran cereal

Rationale :

🔹 Bran cereal is high in fiber, which promotes gastric emptying and reduces intra-abdominal pressure, helping decrease reflux episodes.

🔹 GERD management includes choosing low-fat, non-acidic foods, and bran cereal meets these criteria.

🔹 High-fiber foods support healthy digestion and prevent constipation, which can otherwise increase abdominal pressure and worsen reflux.

🔹 Bran cereal does not stimulate excessive gastric acid secretion, making it safer for clients with esophageal irritation.

🔹 Selecting bland, fiber-rich options demonstrates understanding of dietary modification as a first-line treatment for GERD.

Tomato soup

🔹 Tomato products are highly acidic, which can irritate the esophageal mucosa.

🔹 Acidic foods increase the likelihood of heartburn and reflux symptoms.

Hot cocoa

🔹 Chocolate contains methylxanthines, which relax the lower esophageal sphincter (LES).

🔹 Relaxation of the LES increases the risk of gastric contents refluxing into the esophagus. Fried chicken

🔹 Fried foods are high in fat, which delays gastric emptying.

🔹 High-fat meals increase LES relaxation, worsening reflux symptoms.

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Answer 4

Correct Answers:

Abdominal distention

Rationale :

🟣 Paralytic ileus is a temporary loss of intestinal peristalsis commonly occurring after abdominal or orthopedic surgery due to anesthesia and opioid use.

🟣 When peristalsis stops, gas and intestinal contents accumulate, leading to visible and palpable abdominal distention.

🟣 The client may also have absent or hypoactive bowel sounds, nausea, and inability to pass flatus, all associated with bowel inactivity.

🟣 Distention occurs because the intestines are not propelling contents forward, resulting in intestinal dilation and bloating.

🟣 Recognizing abdominal distention early is critical to prevent complications such as bowel obstruction or perforation.

Oliguria

🟣 Oliguria refers to decreased urine output and indicates a renal or fluid balance issue.

🟣 It is not directly associated with impaired intestinal motility seen in paralytic ileus.

Watery stool

🟣 Watery stool indicates increased intestinal motility or infection.

🟣 Paralytic ileus involves decreased or absent bowel movement, not diarrhea.

Dizziness

🟣 Dizziness may result from hypotension or fluid imbalance.

🟣 It is not a specific sign of decreased gastrointestinal peristalsis.

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Answer 5

Correct Answers:

"Apply the patch prior to traveling."

Rationale :

🟢 Transdermal scopolamine is an anticholinergic medication used to prevent motion sickness by blocking muscarinic receptors in the vestibular system.

🟢 The patch should be applied at least 4 hours before travel to allow adequate absorption and therapeutic blood levels to develop.

🟢 Applying it prior to exposure ensures preventive action rather than treatment after symptoms begin.

🟢 The patch provides continuous medication delivery for up to 72 hours, making timing essential for effectiveness.

🟢 Teaching pre-application demonstrates understanding of prophylactic medication use, which is key in motion sickness management.

"Replace a dislodged patch onto the same location."

🟢 Once a patch becomes dislodged, it should be discarded and replaced with a new patch on a different clean, dry area.

🟢 Reapplying the same patch may result in inconsistent dosing and reduced adhesion.

"Place the patch on your upper arm."

🟢 The correct placement site is behind the ear (mastoid area), not the arm.

🟢 This location allows optimal absorption through thin, well-vascularized skin.

"Store unused patches in the refrigerator."

🟢 Scopolamine patches should be stored at room temperature, away from heat and moisture.

🟢 Refrigeration can alter medication integrity and is not recommended by manufacturers.

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Answer 6

Correct Answers:

Note whether the client has a living will.

Rationale :

🔵 During admission documentation, the nurse must assess and record the client’s advance directives, including whether a living will is in place.

🔵 Acute care facilities are legally required to ask about and document the presence of advance directives under federal patient self-determination laws.

🔵 Knowing if a client has a living will ensures that end-of-life preferences are respected and followed if the client becomes unable to make decisions.

🔵 Documentation of advance directives promotes ethical practice and client autonomy, which are foundational nursing responsibilities.

🔵 Admission data should include legal, psychosocial, and medical information, and the presence of a living will is part of the legal health record.

"Chart a summary of the data at the change of the shift."

🔵 Admission data should be documented immediately after assessment, not delayed until shift change.

🔵 Delaying documentation increases the risk of omission or inaccuracy in the medical record.

"Document the client's vital signs obtained by an assistive personnel."

🔵 The nurse must validate and assess data before entering it into the permanent health record.

🔵 Simply documenting AP-collected data without verification does not reflect appropriate professional accountability.

"Begin charting with an evaluation of the data."

🔵 Documentation follows the nursing process, which begins with assessment, not evaluation.

🔵 Evaluation occurs after interventions, not at the initial admission stage.

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Answer 7

Correct Answers:

"A nurse may share a client's history with unit staff to determine a treatment plan."

Rationale :

🟡 In mental health settings, information may be shared among members of the healthcare team on a need-to-know basis for treatment, payment, and operations under confidentiality laws.

🟡 Sharing relevant client history with unit staff supports development of a safe, individualized treatment plan and promotes continuity of care.

🟡 This type of communication falls under permitted disclosures for treatment purposes, which do not require additional client authorization.

🟡 Only information that is directly related to the client’s care should be shared, maintaining the principle of minimum necessary disclosure.

🟡 This practice upholds both client safety and therapeutic effectiveness while still protecting privacy boundaries.

"A provider may share the details of a client's individual therapy session with the client's family."

🟡 Psychotherapy session details are highly protected and generally require explicit written client authorization before disclosure.

🟡 Family members do not automatically have access to private therapy content unless the client grants permission.

"A nurse may review a client's psychotherapy notes from an outpatient clinic."

🟡 Psychotherapy notes receive special protection and are not part of the general medical record accessible to all staff.

🟡 Access typically requires specific authorization and is restricted even within the healthcare system.

"A provider has the legal privilege to waive a client's right to confidentiality."

🟡 Client confidentiality is a legal right of the client, not the provider.

🟡 Providers cannot waive this right except in specific legally mandated circumstances such as imminent harm.

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Answer 8

Correct Answers:

Shave or clip hair on skin areas adjacent to the burn wounds.
Change gloves between treatments of different burn wounds.
Clean the burn wounds at least every 24 hr.

Rationale :

Shave or clip hair on skin areas adjacent to the burn wounds.

🔴 Removing hair around burn areas reduces the presence of microorganisms that can colonize wound surfaces.

🔴 Clipping (not shaving with a razor) decreases the risk of microabrasions, which could introduce infection.

🔴 Hair removal improves adherence of dressings and topical antimicrobial agents, promoting wound healing.

🔴 Burned skin loses its protective barrier, increasing vulnerability to bacterial invasion.

Change gloves between treatments of different burn wounds.

🔴 Each burn wound should be treated as a separate contaminated site to prevent cross-contamination.

🔴 Changing gloves reduces transfer of pathogens from one wound area to another.

🔴 Burn clients are at high risk for systemic infection and sepsis, making strict infection control critical.

🔴 This practice aligns with standard and contact precautions in burn care management.

Clean the burn wounds at least every 24 hr.

🔴 Regular cleansing removes necrotic tissue, debris, and bacterial buildup.

🔴 Daily wound care decreases microbial growth and lowers the risk of burn wound infection.

🔴 Cleaning supports proper assessment of wound progression and healing status.

🔴 Maintaining a clean wound environment is essential because burns compromise the skin’s primary defense barrier.

Clean equipment dedicated to use with the client every 48 hr.

🔴 Equipment must be cleaned according to facility protocol and typically after each use, not every 48 hours.

🔴 Delayed cleaning increases the risk of nosocomial infection transmission.

Rinse the burn areas with cool water after debridement.

🔴 Cool water is appropriate immediately after an acute burn injury, not after debridement during ongoing care.

🔴 Post-debridement care requires sterile solutions, not routine cool water rinsing.

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Answer 9

Correct Answers:

Instruct the client to maintain a full bladder for the procedure.

Rationale :

🟠 During early pregnancy (typically before 20 weeks’ gestation), a full bladder helps elevate the uterus, making it easier to visualize with ultrasound and reducing the risk of accidental injury.

🟠 A distended bladder improves ultrasound guidance accuracy, which is essential for safe needle insertion into the amniotic sac.

🟠 Proper visualization decreases the likelihood of placental puncture or fetal injury.

🟠 Amniocentesis is performed to obtain amniotic fluid for genetic, chromosomal, or neural tube defect testing, and preparation enhances procedural safety.

🟠 Teaching about bladder preparation demonstrates understanding of pre-procedure nursing responsibilities.

Administer a tocolytic 30 min before the procedure.

🟠 Tocolytics are not routinely given before an amniocentesis unless there is a specific indication for uterine irritability.

🟠 The procedure itself does not typically require medication to suppress contractions.

Monitor the fetal heart rate throughout the procedure.

🟠 Fetal heart rate is assessed before and after the procedure, not continuously during it.

🟠 Continuous monitoring is not standard practice for routine amniocentesis.

Place the client in Trendelenburg position during the procedure.

🟠 The client is positioned supine with slight elevation, not in Trendelenburg.

🟠 Trendelenburg positioning is unnecessary and may cause maternal discomfort or hypotension.

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Answer 10

Correct Answers:

Place the client on her side.

Rationale :

🟣 After an eclamptic seizure, the priority is maternal airway protection and prevention of aspiration, and placing the client in a side-lying position helps maintain a patent airway.

🟣 The lateral position reduces the risk of supine hypotensive syndrome by relieving pressure on the inferior vena cava, improving maternal circulation.

🟣 Turning the client to her side also promotes optimal uteroplacental perfusion, which supports fetal oxygenation following the hypoxic stress of a seizure.

🟣 During a seizure, excessive salivation and decreased consciousness increase aspiration risk, making positioning a critical immediate nursing intervention.

🟣 Airway, breathing, and circulation (ABCs) always take priority over fetal monitoring or procedural interventions after a seizure event.

Initiate an amnioinfusion.

🟣 Amnioinfusion is used to dilute thick meconium or relieve cord compression during labor, not for seizure management.

🟣 It does not address maternal airway protection or stabilization following eclampsia.

Administer calcium gluconate via IV bolus.

🟣 Calcium gluconate is the antidote for magnesium sulfate toxicity, not for treating an active eclamptic seizure unless toxicity is suspected.

🟣 Routine post-seizure management focuses first on airway stabilization and safety.

Apply an internal fetal heart monitor.

🟣 Internal monitoring requires cervical dilation and ruptured membranes, and it is not the priority immediately after a seizure.

🟣 Maternal stabilization must occur before initiating invasive fetal monitoring.

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QLexNursing

1 :
A nurse is verifying how a client who is postpartum will use a car seat for her newborn. Which of the following statements should the nurse identify as an indication that the client understands the safe use of a car seat?

2 :
A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

3 :
A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

4 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

5 :
A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?

6 :
A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

7 :
A nurse is teaching a group of unit nurses in a mental health facility about maintaining client confidentiality. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is caring for a client who has both superficial and deep partial-thickness burns on his arms and legs. Which of the following infection control strategies should the nurse use? (Select all that apply.)

9 :
A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

10 :
A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure. Which of the following actions should the nurse take following the seizure?

QLexNursing

1 : A nurse is verifying how a client who is postpartum will use a car seat for her newborn. Which of the following statements should the nurse identify as an indication that the client understands the safe use of a car seat?

2 : A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

3 : A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

4 : A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

5 : A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?

6 : A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

7 : A nurse is teaching a group of unit nurses in a mental health facility about maintaining client confidentiality. Which of the following statements should the nurse include in the teaching?

8 : A nurse is caring for a client who has both superficial and deep partial-thickness burns on his arms and legs. Which of the following infection control strategies should the nurse use? (Select all that apply.)

9 : A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

10 : A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure. Which of the following actions should the nurse take following the seizure?

1 :
A nurse is verifying how a client who is postpartum will use a car seat for her newborn. Which of the following statements should the nurse identify as an indication that the client understands the safe use of a car seat?

2 :
A nurse is teaching a client who has generalized anxiety disorder about ways to help manage stress. Which of the following instructions should the nurse give the client about using progressive relaxation?

3 :
A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

4 :
A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?

5 :
A nurse is teaching a client about using transdermal scopolamine to treat motion sickness. Which of the following instructions should the nurse include?

6 :
A nurse is documenting admission data for a client on an acute care facility. Which of the following actions should the nurse take?

7 :
A nurse is teaching a group of unit nurses in a mental health facility about maintaining client confidentiality. Which of the following statements should the nurse include in the teaching?

8 :
A nurse is caring for a client who has both superficial and deep partial-thickness burns on his arms and legs. Which of the following infection control strategies should the nurse use? (Select all that apply.)

9 :
A nurse is planning care for a client prior to an amniocentesis. Which of the following actions should the nurse include in the plan of care?

10 :
A nurse is caring for a client who is at 33 weeks of gestation, has eclampsia, and is experiencing a seizure. Which of the following actions should the nurse take following the seizure?