A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Limit teaching sessions about the procedure to 20 min.

Ask the parents to wait outside the room during the procedure.

Instruct the child in deep-breathing methods prior to the procedure.

Explain in simple terms how the procedure will affect the child.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Limit teaching sessions about the procedure to 20 min: While preschoolers have limited attention spans, the focus should be on using age-appropriate language and explanations rather than strictly timing the teaching session. The quality and clarity of instruction are more important.

B. Ask the parents to wait outside the room during the procedure: Preschoolers often feel safer and more cooperative when a parent is present. Removing parents can increase anxiety and resistance, so parental presence is encouraged.

C. Instruct the child in deep-breathing methods prior to the procedure: Deep-breathing exercises can help with relaxation, but preschoolers may have difficulty understanding or performing them effectively. Simple explanations and reassurance are more appropriate.

D. Explain in simple terms how the procedure will affect the child: Providing a clear, age-appropriate explanation helps the preschooler understand what to expect, reduces fear, and promotes cooperation. Using simple terms tailored to the child’s developmental level is the most effective preparation.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. "Schedule rest periods during the day.": Fatigue is a common symptom of multiple sclerosis. Scheduling rest periods helps conserve energy, prevent exacerbation of symptoms, and improve overall functioning without overtaxing the client.

B. "Soak in a hot bath.": Heat can worsen multiple sclerosis symptoms by temporarily increasing nerve conduction delays. Hot baths may trigger fatigue or weakness and are generally discouraged.

C. "Perform aerobic activities three times per week.": While gentle exercise is beneficial, intense aerobic activity can exacerbate fatigue and heat sensitivity in clients with multiple sclerosis. Exercise should be balanced with rest periods.

D. "Have your partner complete activities of daily living for you.": Encouraging total dependence can reduce independence and self-efficacy. Clients should perform activities within their capacity to maintain function while pacing themselves appropriately.

A. Administer betamethasone to the client. B. Administer magnesium sulfate to the client. C. Monitor fetal heart rate every 4 hr. D. Monitor the client's temperature every 2 hr.

Correct Answer is D

Explanation

Rationale:
A. Administer betamethasone to the client: Betamethasone is given to promote fetal lung maturity in preterm labor, typically before 34 weeks of gestation. At 37 weeks, the fetus is considered term, so corticosteroids are not indicated.

B. Administer magnesium sulfate to the client: Magnesium sulfate is used for neuroprotection in preterm labor or for seizure prophylaxis in preeclampsia. Since this client is at term without preeclampsia, magnesium sulfate is not indicated.

C. Monitor fetal heart rate every 4 hr: Continuous or frequent fetal heart rate monitoring is recommended after spontaneous rupture of membranes to detect signs of fetal distress or infection. Monitoring only every 4 hours is insufficient.

D. Monitor the client's temperature every 2 hr: Maternal infection, such as chorioamnionitis, is a significant risk after spontaneous rupture of membranes. Monitoring the client’s temperature every 2 hours allows early detection of infection and timely intervention.

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A nurse is preparing to perform a dressing change on a preschooler. Which of the following actions should the nurse take to prepare the child for the procedure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client who has multiple sclerosis. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is caring for a client who is at 37 weeks of gestation and experiences a spontaneous rupture of membranes before labor has begun. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

A nurse is reviewing the medication administration record of a client who has benign prostatic hyperplasia (BPH). The client asks the nurse about taking saw palmetto. The nurse should instruct the client that which of the following medications interacts adversely with saw palmetto?

A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

A nurse is caring for a client who has cancer and is being transferred to hospice care. The client's daughter tells the nurse, "I'm not sure what to say to my mom if she asks me about dying." Which of the following responses by the nurse is appropriate? (Select all that apply.)

A nurse is reviewing the medical record of a client who had abdominal surgery 2 days ago. The nurse should identify that which of the following findings indicates the client is at risk for delayed wound healing?