A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make?

This medication will increase the immunity of your newborn.

This medication will decrease the risk of hemorrhage in your newborn.

This medication will decrease the possibility of your newborn developing jaundice.

This medication will increase the absorption of nutrients in the intestines.

Answer and Explanation

The Correct Answer is B

A. This medication will increase the immunity of your newborn.: Vitamin K does not directly affect the immunity of a newborn. It plays a crucial role in blood clotting, not immune function.

B. This medication will decrease the risk of hemorrhage in your newborn.: Vitamin K is given to newborns to prevent bleeding or hemorrhagic disease, as newborns have low levels of vitamin K at birth, which is essential for clotting.

C. This medication will decrease the possibility of your newborn developing jaundice.: Vitamin K does not have a role in preventing jaundice, which is related to elevated bilirubin levels in the blood.

D. This medication will increase the absorption of nutrients in the intestines.: Vitamin K does not influence nutrient absorption in the intestines; it primarily supports blood clotting by helping in the synthesis of clotting factors.

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Correct Answer is D

Explanation

A. Instructing the client to hold the drainage bag at waist height when ambulating is incorrect. The drainage bag should always be kept below the level of the bladder to prevent urine backflow, which can lead to infections (catheter-associated urinary tract infections - CAUTIs).

B. Coiling the tubing on the bed above the collection bag is incorrect. Tubing should be secured below bladder level without kinks or loops to allow for continuous urine drainage and prevent urinary stasis and infection.

C. Collecting a sterile specimen from the urinary drainage bag is incorrect. Urine in the drainage bag is not sterile and may contain bacteria, leading to inaccurate results. A specimen should be collected from the designated port on the catheter tubing using aseptic technique.

D. Securing the tubing with adhesive tape to the lower abdomen is correct. For male clients, securing the catheter to the lower abdomen prevents urethral trauma and tension. For female clients, the catheter is typically secured to the inner thigh to minimize movement and irritation.

A. Contact the provider within 48 hr to obtain a prescription for the restraints. B. Remove the restraints from the client's wrists every 2 hr. C. Check that one finger will fit between the client's wrists and the restraints. D. Fasten the restraints' ties to the bed's side rails.

Correct Answer is B

Explanation

A. Contacting the provider within 48 hr is incorrect. A prescription for restraints must be obtained within 1 hour of applying restraints, not within 48 hours. The nurse should ensure that this prescription is obtained promptly.

B. Removing the restraints every 2 hr is correct. The nurse should remove the restraints every 2 hours to assess the skin, provide range-of-motion exercises, and offer comfort. This ensures that the client is not harmed from prolonged restraint use.

C. Checking that one finger fits between the client's wrists and the restraints is incorrect. The nurse should ensure that the restraints are snug but not too tight to cause injury, typically allowing for two fingers of space, not just one.

D. Fastening the restraints' ties to the bed's side rails is incorrect. Restraints should be fastened to a movable part of the bed frame (not side rails) to prevent injury or accidental strangulation. The side rails can move and cause undue tension on the restraints.

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A nurse is preparing a vitamin K injection to give to a newborn. The newborn's mother questions the purpose of the medication. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an indwelling catheter with a urinary drainage system. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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