The nurse is continuing to care for the child.

Exhibits

After reviewing the discharge instructions with the family, which of the following statements by a parent indicate an understanding of the teaching?
For each statement by the parent, click to specify if the statement reflects an understanding or indicates a need for reinforcement of the discharge teaching.

"We should notify the provider if the cast becomes loose over time."

"We should expect the swelling and tingling to worsen before it gets better."

"We need to be very careful about how we handle the cast for the first 2 days while it dries."

"It is important that our child avoids placing anything inside the cast.

"We should prop the casted arm on pillows for the next 24 hours."

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"}}

Rationale:

• "We should notify the provider if the cast becomes loose over time.": A loose cast can fail to immobilize the fracture properly, risking displacement or delayed healing. Recognizing this and contacting the provider demonstrates proper understanding of cast care.

• "We should expect the swelling and tingling to worsen before it gets better.": While mild swelling and tingling may occur, increasing or worsening neurovascular symptoms can indicate complications such as compartment syndrome. The parent needs reinforcement that any worsening sensation or cold fingers should prompt immediate provider notification rather than being expected.

• "We need to be very careful about how we handle the cast for the first 2 days while it dries.": Handling a wet cast improperly can deform it and compromise fracture stabilization. Awareness of this indicates correct knowledge of initial cast care.

• "It is important that our child avoids placing anything inside the cast.": Inserting objects into the cast can cause skin irritation, pressure ulcers, or infection. Avoiding this demonstrates understanding of safe cast management.

• "We should prop the casted arm on pillows for the next 24 hours.": Elevation of the casted limb reduces swelling and promotes comfort. This reflects correct knowledge of post-cast care.

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Correct Answer is D

Explanation

Rationale:
A. "The provider can give you a referral for your baby to see an infectious disease provider.": Referring to a specialist does not address the parents’ knowledge or concerns about immunizations. The priority is to engage in a discussion to understand their perspective.

B. "Your baby's immunizations should be up to date before they are able to travel with you by airplane.": Framing immunizations only around travel requirements may seem judgmental and does not address the broader health benefits of vaccination.

C. "You don't have to immunize your baby against diseases that are no longer common.": This statement is misleading because many vaccine-preventable diseases can reemerge if immunization rates drop. It could reinforce misconceptions rather than promoting safe health practices.

D. "Let's talk about what you already know about immunizing your baby.": Beginning with an open-ended, nonjudgmental discussion allows the nurse to assess the parents’ knowledge, beliefs, and concerns. This approach supports informed decision-making and provides an opportunity for accurate, tailored education about vaccines.

A. Assess the client's lung sounds prior to the infusion. B. Prime the infusion tubing with 0.45% sodium chloride. C. Don sterile gloves to prepare the blood administration setup. D. Verify with another nurse that the unit of blood is compatible with the client's blood type. E. Infuse the blood over 4 hr.

Correct Answer is ["A","D"]

Explanation

Rationale:
A. Assess the client's lung sounds prior to the infusion: Baseline lung assessment helps detect early signs of fluid overload or transfusion-associated circulatory overload (TACO), which is especially important in older adults.

B. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) is compatible with blood products. Hypotonic solutions such as 0.45% sodium chloride can cause hemolysis of red blood cells.

C. Don sterile gloves to prepare the blood administration setup: Clean gloves are sufficient for preparing and administering blood transfusions. Sterile gloves are not required unless performing a sterile procedure.

D. Verify with another nurse that the unit of blood is compatible with the client's blood type: Double verification of the client’s identity and blood compatibility prevents hemolytic transfusion reactions due to mismatched blood.

E. A single blood administration set should not be used for more than 4 hours total due to the risk of bacterial growth. More importantly, running 2 units over a single 4 hour window would mean infusing the blood far too quickly for an older adult, drastically increasing their risk of volume overload. Each unit should be scheduled separately with a careful assessment in between.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is talking with the parents of a 2-month-old infant who have chosen to not immunize the infant. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is planning to administer 2 units of packed RBCs to an older adult client who has anemia. Which of the following actions should the nurse plan to take? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

A nurse is preparing to administer three medications to a client who is receiving continuous enteral feedings through an NG tube. Which of the following actions is appropriate for the nurse to take?

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 in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

A nurse is preparing to administer testosterone gel to a client who has hypogonadism. Which of the following actions should the nurse take?

A nurse is reviewing a client's laboratory values. Which of the following should the nurse review to evaluate the client's nutritional status?

A nurse is initiating bladder retraining for a client who has urge urinary incontinence. Which of the following instructions should the nurse give the client?

A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

A nurse is teaching a client about dietary recommendations while breastfeeding. Which of the following client statements should the nurse identify as an indication of understanding the teaching?