Question

A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

Answer 1

Correct Answers:

Wash the area around the base of the cord with water.

Rationale :

🟢 The cord should be kept clean and dry to promote natural detachment and healing.

🟢 Washing gently with plain water helps remove dirt or residue without using harsh substances.

🟢 The diaper should be folded below the cord to keep it exposed to air and prevent moisture buildup.

🟢 Applying ointments or covering it can delay cord separation or lead to infection.

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Answer 2

Correct Answers:

"The client can resume control of health care after a temporary loss of competency."

Rationale :

🟡 Advance directives allow clients to assign decision-making authority temporarily if they become incapacitated.

🟡 If competency is regained, the client has the right to resume full control over their care decisions.

🟡 A health care surrogate does not need to be family—any competent adult can be chosen.

🟡 Providers are legally required to follow a valid advance directive unless ethically exempt.

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Answer 3

Correct Answers:

Instruct the client about the use of telehealth services.

Rationale :

🔷 Telehealth expands access to care for clients in rural or underserved areas.

🔷 It supports routine monitoring, especially for chronic conditions like diabetes.

🔷 This method allows timely communication with providers without the need for long-distance travel.

🔷 It promotes independence while maintaining disease management.

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Answer 4

Correct Answers:

Corn tortilla with black beans

Rationale :

🟣 Clients with celiac disease must avoid gluten, which is found in wheat, barley, and rye.

🟣 Corn and beans are naturally gluten-free and safe for inclusion in the diet.

🟣 Foods like rye bread, wheat pasta, or barley-based soup are contraindicated.

🟣 Careful food selection prevents intestinal inflammation and malabsorption.

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Answer 5

Correct Answers:

Fever

Rationale :

🔴 Clozapine can cause agranulocytosis, a life-threatening condition marked by immune suppression.

🔴 Fever may be the first sign of infection due to a low white blood cell count.

🔴 The nurse must report this immediately to avoid delays in lab monitoring or medication hold.

🔴 Other symptoms (polyuria, diarrhea, diaphoresis) are less urgent or unrelated to clozapine's major risk.

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Answer 6

Correct Answers:

The client's systolic blood pressure decreases by 25 mm Hg.

Rationale :

🔹 Orthostatic hypotension is defined as a systolic drop of ≥20 mm Hg or diastolic drop of ≥10 mm Hg upon position change.

🔹 A 25 mm Hg systolic decrease clearly meets the criteria for orthostatic hypotension.

🔹 This condition is a common side effect of antihypertensive medications.

🔹 It increases the risk of dizziness, syncope, and falls, especially in older adults.

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Answer 7

Correct Answers:

"I will position my baby at a 45-degree angle in the car seat."

Rationale :

🟡 Positioning a newborn at a 45-degree angle helps maintain an open airway and prevents slumping.

🟡 The shoulder straps should be at or just below the shoulders, not 3 inches above.

🟡 Infants should remain rear-facing until at least 2 years old, not just 1 year.

🟡 The retainer clip should be positioned at armpit level, not on the upper abdomen.

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Answer 8

Correct Answers:

Suction the client's airway.

Rationale :

🔴 A high-pressure alarm on the ventilator often indicates airflow obstruction, commonly from secretions.

🔴 Suctioning clears the airway and resolves the increased resistance.

🔴 If unaddressed, the client is at risk for hypoxia and distress.

🔴 Other interventions (leak check, cuff issues) relate more to low-pressure alarms.

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Answer 9

Correct Answers:

Scrambled eggs

Rationale :

🟣 Scrambled eggs have a soft, cohesive texture, which makes them easier and safer to swallow.

🟣 Clients with dysphagia should avoid dry, sticky, or crumbly foods like crackers or peanut butter.

🟣 Scrambled eggs reduce the risk of aspiration and help maintain nutritional intake.

🟣 Soft, moist, and easily managed textures are essential for safe swallowing.

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Answer 10

Correct Answers:

Position the sterile drape leaving the perineum exposed.

Rationale :

🔸 Positioning the sterile drape is part of maintaining aseptic technique before touching the client.

🔸 This step creates a sterile field, which is essential to prevent catheter-associated infections.

🔸 Lubrication, cleansing, and balloon prep follow only after proper draping.

🔸 Starting with positioning ensures organized and sterile catheter insertion.

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QLexNursing

1 :
A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

2 :
A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

3 :
A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

4 :
A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

5 :
A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

6 :
A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

7 :
A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

8 :
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

9 :
A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend?

10 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

QLexNursing

1 : A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

2 : A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

3 : A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

4 : A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

5 : A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

6 : A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

7 : A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

8 : While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

9 : A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend?

10 : A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?

1 :
A nurse is teaching a client who is postpartum about caring for their newborn's umbilical cord. Which of the following instructions should the nurse include?

2 :
A nurse is teaching a newly licensed nurse about advance directives. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

3 :
A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

4 :
A nurse is providing dietary teaching to the guardian of a preschooler who has celiac disease. Which of the following foods should the nurse recommend including in the preschooler's diet?

5 :
A nurse is assessing a client who has schizophrenia prior to administering the client's next dose of clozapine. Which of the following findings should the nurse report to the provider?

6 :
A nurse is caring for a client who is taking antihypertensive medication and is moving from a supine to a sitting position. Which of the following findings should indicate to the nurse that the client is experiencing orthostatic hypotension?

7 :
A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

8 :
While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds. Which of the following actions should the nurse take?

9 :
A nurse is assisting in the selection of foods for a client who has dysphagia caused by a stroke. Which of the following foods should the nurse recommend?

10 :
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take first?