which of the following statements if made by the parents of a newborn does not indicate a need for further teaching about cord care

NCLEX-PN

Best NCLEX Next Gen Prep

1. Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?

A. “I should not put alcohol on my baby’s cord 3–4 times a day.”
B. “I should not put the baby’s diaper on so that it covers the cord.”
C. “I should call the physician if the cord becomes dark.”
D. “I should wash my hands before and after I take care of the cord.”

Correct answer: “I should not put the baby’s diaper on so that it covers the cord.”

Rationale: Parents should be taught not to cover the cord with a diaper to allow for air exposure and drying, preventing infection. The statement 'I should put alcohol on my baby’s cord 3–4 times a day' indicates a need for further teaching as current recommendations do not include using alcohol on the cord, which can interfere with natural healing. While it is normal for the cord to turn dark as it dries, so the statement 'I should call the physician if the cord becomes dark' is accurate, it is not the best answer for this question. Washing hands before and after caring for the cord is important to prevent the transfer of pathogens, so this statement does not require further teaching.

2. When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:

A. “Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.”
B. “If you haven’t been sexually active throughout your life, you will not be able to participate in sexual activity in old age.”
C. “When intercourse isn’t possible, many of your sexual needs can be met through intimacy and touch.”
D. “You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time.”

Correct answer: “Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes.”

Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.

3. At what age are yearly mammograms recommended to start?

A. Yearly mammograms are recommended starting at age 25.
B. Yearly mammograms are recommended starting at age 40.
C. Yearly mammograms are not necessary unless there is a family history of breast cancer.
D. Yearly mammograms are recommended starting at age 20 and continuing until menopause begins.

Correct answer: Yearly mammograms are recommended starting at age 40.

Rationale: The correct answer is B. The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast examination should be done about every 3 years for women in their 20s and 30s and every year for women age 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-examination should be done monthly starting when a woman is in her 20s. Choice A is incorrect as mammograms are not recommended to start at age 25. Choice C is incorrect as yearly mammograms are still recommended even without a family history of breast cancer. Choice D is incorrect as the recommended age for starting yearly mammograms is 40, not 20.

4. A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client’s ability to maintain a patent airway because of which factor involved in the normal aging process?

A. Increased respiratory system compliance
B. Decreased number of alveoli and increased function of those remaining
C. Decreased older client’s ability to clear secretions
D. Increased production of surfactant

Correct answer: Decreased older client’s ability to clear secretions

Rationale: The correct answer is 'Decreased older client’s ability to clear secretions.' Respiratory changes related to the normal aging process decrease an older adult’s ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways, and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished. Choices A, B, and D are incorrect. Choice A is incorrect because respiratory system compliance decreases with aging. Choice B is incorrect as the number of alveoli does not significantly decrease in healthy older adults. Choice D is incorrect as the production of surfactant does not usually decrease with aging.

5. Which of the following vaccines contains a live virus?

A. varicella
B. IPV
C. DTaP
D. hepatitis B

Correct answer: varicella

Rationale: The correct answer is varicella. Varicella vaccine contains a live, weakened form of the varicella-zoster virus. Choice B, IPV (inactivated poliovirus vaccine), is an inactivated vaccine, not a live virus vaccine. Choices C and D, DTaP (diphtheria, tetanus, and acellular pertussis vaccine) and hepatitis B vaccine, respectively, do not contain live viruses. Varicella is the only live virus vaccine among the options.