a nurse is reviewing discharge instructions with the parents of a newborn which of the following statements indicates a need for further teaching
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D. Leaving the baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash. Choices A, B, and C are correct as placing the baby on its back to sleep, giving the baby a pacifier at bedtime, and keeping the baby's crib free of blankets and toys are appropriate measures to ensure the newborn's safety and reduce the risk of Sudden Infant Death Syndrome (SIDS).

2. A nurse is caring for a toddler with respiratory syncytial virus (RSV). Which action should the nurse take?

Correct answer: A

Rationale: Using a designated stethoscope for the toddler is crucial to reduce the risk of spreading RSV to other patients. Choice B is incorrect because N95 respirator masks are not specifically indicated for RSV. Choice C is unnecessary as RSV does not require isolation in a negative pressure room. Choice D is incorrect because the gown should be removed after leaving the room to prevent transmission of pathogens to other areas.

3. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?

Correct answer: C

Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.

4. A nurse is caring for four clients. Which client should the nurse assess first?

Correct answer: C

Rationale: The correct answer is C. The client with hypothyroidism who is stuporous should be assessed first as this may indicate a critical condition, possibly related to severe hypothyroidism. Stupor is a state of near-unconsciousness or insensibility, suggesting a decline in neurological function that requires immediate evaluation. Choices A, B, and D do not present with immediate life-threatening conditions that require urgent assessment. While chemotherapy, post-appendectomy complications, and burn care are important, they do not pose the same level of immediate risk as a stuporous client.

5. A nurse is providing teaching to a client who has tuberculosis (TB) and is prescribed rifampin. Which of the following statements should the nurse include in the teaching?

Correct answer: A

Rationale: The correct answer is A. Rifampin can cause harmless red-orange discoloration of bodily fluids, including urine, sweat, and tears. Clients should be informed about this side effect. Choice B is incorrect because the duration of rifampin therapy for TB is typically longer than 6 months. Choice C is incorrect as there is no need to avoid dairy products while on rifampin. Choice D is incorrect as rifampin does not cause sensitivity to sunlight.

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