a nurse provides instructions to a mother about crib safety for her infant which statement by the mother indicates a need for further instructions

NCLEX-PN

Nclex Questions Management of Care

1. A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions?

A. ''Wood surfaces on the crib need to be free of splinters and cracks.''
B. ''I need to keep large toys out of the crib.''
C. ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''
D. ''The drop side needs to be impossible for my infant to release.''

Correct answer: ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.''

Rationale: The correct answer is, ''The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body.'' This statement indicates a need for further instructions as the distance between the slats should be no more than 2⅜ inches to prevent entrapment of the infant’s head and body, not 4 inches. Allowing a larger gap can pose a risk of entrapment or injury to the infant. Keeping large toys out of the crib is essential to prevent the infant from using them to climb out, which could result in serious injuries. Ensuring the drop side of the crib is impossible for the infant to release is crucial to prevent falls and injuries. Additionally, maintaining wood surfaces on the crib free of splinters, cracks, and lead-based paint is vital for the infant's safety and well-being.

2. What should be included in the assessment of a client with a cast?

A. capillary refill, warm toes, no discomfort.
B. posterior tibial pulses, warm toes.
C. moist skin essential, pain threshold.
D. discomfort of the metacarpals.

Correct answer: capillary refill, warm toes, no discomfort.

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.

3. Which of the following clients requires airborne precautions?

A. a client with fever, chills, vomiting, and diarrhea
B. a client suspected of varicella (chickenpox)
C. a client with abdominal pain and purpura
D. a client diagnosed with AIDS

Correct answer: a client suspected of varicella (chickenpox)

Rationale: The correct answer is 'a client suspected of varicella (chickenpox).' Chickenpox is an acute, infectious airborne illness that requires airborne precautions, including wearing a respirator mask for direct contact with the patient. Choices A, C, and D do not typically require airborne precautions. Choice A describes symptoms that may indicate a gastrointestinal infection but do not require airborne precautions. Choice C mentions abdominal pain and purpura, which are not specific to an airborne illness. Choice D, a client diagnosed with AIDS, does not necessitate airborne precautions unless there are additional infectious conditions present that require such measures.

4. The nurse is educating a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?

A. “Do not sit on toilet seats without protection.”
B. “Oral sex can transmit the virus.”
C. “This infection can be transmitted via intercourse even when you do not feel ill.”
D. “Try to drink plenty of fluids after sex to flush the reproductive tract.”

Correct answer: “This infection can be transmitted via intercourse even when you do not feel ill.”

Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It is crucial to educate the patient that the infection can be transmitted via intercourse even when asymptomatic to prevent its spread. Choice A is incorrect as sitting on toilet seats without protection does not transmit genital herpes. Choice B is incorrect because oral sex can transmit the virus. Choice D is also incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.

5. Which action by the nurse represents the ethical principle of benevolence?

A. The nurse administers an immunization to a child even though it may cause discomfort
B. The nurse follows a plan of care designed to relieve pain in a client with cancer
C. The nurse provides equal amounts of care to all assigned clients on the basis of illness acuity
D. The nurse upholds a client’s decision to refuse chemotherapy for lung cancer

Correct answer: The nurse administers an immunization to a child even though it may cause discomfort

Rationale: Benevolence is taking action to help others. In this scenario, administering an immunization to a child, even though it may cause discomfort, aligns with the principle of benevolence as the benefits of protection from disease outweigh the temporary discomfort. Fidelity refers to keeping promises made to clients, families, and other healthcare professionals. Autonomy is a person’s independence, and respecting autonomy means agreeing to respect an individual’s right to determine their course of action. Justice refers to fairness and equity, including the fair allocation of resources, such as nursing care for all clients. Choice B is incorrect as it pertains more to the ethical principle of beneficence rather than benevolence, which focuses on doing good for others without an expectation of something in return. Choices C and D are incorrect as they do not directly align with the principle of benevolence.