Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assisting the parent of a preterm newborn to perform skin-to-skin care to enhance parental bonding. Which of the following actions should the nurse take?
A. Instruct the parent to remove his shirt.
Instructing the parent to remove their shirt allows for direct skin-to- skin contact between the parent's chest and the preterm newborn, which is commonly known as kangaroo care. This technique promotes bonding, warmth, and comfort for both the parent and the newborn.
B. Place the newborn and parent in a private room that is brightly lit.
Placing the newborn and parent in a private room that is brightly lit might not be optimal for skin-to-skin care, as preterm newborns are sensitive to light and sound. A calm and dimly lit environment is preferred.
C. Place the newborn in a horizontal position in the parent's arms.
Placing the newborn in a horizontal position in the parent's arms is appropriate, as it allows for skin-to-skin contact and facilitates bonding. The newborn's head is positioned near the parent's chest to listen to the heartbeat.
D. Completely undress the newborn.
Completely undressing the newborn is not necessary for skin-to-skin care and may cause discomfort to the newborn. Keeping the newborn dressed in a diaper is sufficient.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
Instructing the parent to remove their shirt allows for direct skin-to- skin contact between the parent's chest and the preterm newborn, which is commonly known as kangaroo care. This technique promotes bonding, warmth, and comfort for both the parent and the newborn.
Choice B rationale:
Placing the newborn and parent in a private room that is brightly lit might not be optimal for skin-to-skin care, as preterm newborns are sensitive to light and sound. A calm and dimly lit environment is preferred.
Choice C rationale:
Placing the newborn in a horizontal position in the parent's arms is appropriate, as it allows for skin-to-skin contact and facilitates bonding. The newborn's head is positioned near the parent's chest to listen to the heartbeat.
Choice D rationale:
Completely undressing the newborn is not necessary for skin-to-skin care and may cause discomfort to the newborn. Keeping the newborn dressed in a diaper is sufficient.
Similar Questions
A nurse is evaluating the effectiveness of the plan of care for a client who has experienced sexual assault. Which of the following findings indicates effectiveness of the plan of care?
A. Exhibits grief response behaviors
Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.
B. States a desire for revenge
Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.
C. Asks for advice about making life decisions
A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.
D. Demonstrates an increase in regressive behavior
Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.
Full Explanation
Choice A rationale:
Exhibiting grief response behaviors may indicate the client is processing emotions related to the assault but may not necessarily indicate effectiveness of the plan of care.
Choice B rationale:
Stating a desire for revenge suggests unresolved anger and is not indicative of effective coping or progress.
Choice C rationale:
A sign of effectiveness in the plan of care for a client who has experienced sexual assault is the client's willingness to seek guidance and support in making important life decisions. This indicates a sense of trust in the nurse and a desire to move forward in a positive way.
Choice D rationale:
Demonstrating an increase in regressive behavior might indicate emotional distress but does not necessarily indicate effectiveness of the plan of care.
A nurse is caring for a 19-year-old client who is dying following a motor vehicle crash. Which of the following individuals should the nurse approach first about considering organ donation?
A. The client's parent
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
B. The client's grandparent
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
C. The client's older sibling
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
D. The client's spouse
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Full Explanation
Choice A rationale:
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
Choice B rationale:
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Choice C rationale:
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
Choice D rationale:
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
A nurse is providing discharge teaching about lymphedema prevention to a client who is 2 days postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?
A. Apply lotion to the incisional site twice daily.
Applying lotion to the incisional site may not be recommended as it could potentially irritate the incision or interfere with wound healing.
B. Avoid measuring blood pressure on the affected arm.
Avoiding blood pressure measurements on the affected arm is important to prevent compromising lymphatic flow and potentially exacerbating lymphedema, a common complication after a modified radical mastectomy.
C. Apply deodorant under the affected arm daily.
Applying deodorant under the affected arm is discouraged, as it may contain chemicals that could irritate the surgical area.
D. Avoid lifting objects greater than 5.4 kg (12 lb).
While lifting heavy objects is generally discouraged after surgery, the specific weight mentioned (5.4 kg or 12 lb) is not consistently supported as a limitation in post- mastectomy care.
Full Explanation
Choice A rationale:
Applying lotion to the incisional site may not be recommended as it could potentially irritate the incision or interfere with wound healing.
Choice B rationale:
Avoiding blood pressure measurements on the affected arm is important to prevent compromising lymphatic flow and potentially exacerbating lymphedema, a common complication after a modified radical mastectomy.
Choice C rationale:
Applying deodorant under the affected arm is discouraged, as it may contain chemicals that could irritate the surgical area.
Choice D rationale:
While lifting heavy objects is generally discouraged after surgery, the specific weight mentioned (5.4 kg or 12 lb) is not consistently supported as a limitation in post- mastectomy care.