Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching about circumcision care with the parent of an infant who just underwent a Plastibell circumcision. Which of the following statements by the parent indicates an understanding of the teaching?
A. "I will apply antibiotic ointment to my baby's penis."
B. "I will make sure that my baby's diaper is applied snugly."
C. "I will wipe away yellow crusts that form around the incision."
D. "I will apply pressure with gauze if I see bleeding."
The parent should apply pressure with gauze if they see bleeding from the circumcision site, as this can indicate a complication such as infection or dislodgement of the plastic ring. The other statements are incorrect because they can interfere with the healing process or cause harm to the infant. Applying antibiotic ointment can cause irritation or allergic reaction, applying a snug diaper can increase pressure and friction on the penis, and wiping away yellow crusts can remove healthy tissue or cause bleeding.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Proctored Exam. Take the full exam now
Full Explanation
The correct answer is D. The parent should apply pressure with gauze if they see bleeding from the circumcision site, as this can indicate a complication such as infection or dislodgement of the plastic ring. The other statements are incorrect because they can interfere with the healing process or cause harm to the infant. Applying antibiotic ointment can cause irritation or allergic reaction, applying a snug diaper can increase pressure and friction on the penis, and wiping away yellow crusts can remove healthy tissue or cause bleeding .
Similar Questions
A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?
A. Submit an incident report to the risk manager
B. Inform the client of the APs actions.
C. Tell the APs to stop the conversation.
The nurse should tell the APs to stop the conversation, as they are violating the client's privacy and confidentiality by discussing their personal information in a public area. This is a breach of ethical and legal principles that can harm the client and expose the healthcare facility to liability. The other actions are not appropriate because they do not address the immediate issue or may escalate the situation unnecessarily. Submitting an incident report may be done after telling the APs to stop, informing the client may cause distress or anger, and documenting the event may not prevent further violations.
D. Document the event in the client's progress notes.
Full Explanation
The correct answer is C. The nurse should tell the APs to stop the conversation, as they are violating the client's privacy and confidentiality by discussing their personal information in a public area. This is a breach of ethical and legal principles that can harm the client and expose the healthcare facility to liability. The other actions are not appropriate because they do not address the immediate issue or may escalate the situation unnecessarily. Submitting an incident report may be done after telling the APs to stop, informing the client may cause distress or anger, and documenting the event may not prevent further violations.
A nurse is collecting data from a client who has a long leg cast on his left leg. Which of the following findings is the priority?
A. Ecchymosis on the inner left thigh
B. Diminished pulses on the affected extremity
Diminished pulses on the affected extremity indicate impaired circulation, which can lead to tissue ischemia, necrosis, and compartment syndrome if not corrected promptly. This is a life-threatening complication that requires immediate intervention such as loosening or cutting off the cast, elevating the limb, or administering vasodilators. The other findings are not as urgent, although they may indicate other problems such as hematoma, infection, or nerve injury that need further assessment and treatment.
C. One fingerbreadth of space between the cast and the skin
D. Client report of muscle spasms of the left leg
Full Explanation
The correct answer is B. Diminished pulses on the affected extremity indicate impaired circulation, which can lead to tissue ischemia, necrosis, and compartment syndrome if not corrected promptly. This is a life-threatening complication that requires immediate intervention such as loosening or cutting off the cast, elevating the limb, or administering vasodilators. The other findings are not as urgent, although they may indicate other problems such as hematoma, infection, or nerve injury that need further assessment and treatment.
A nurse is caring for a client who is 2 days postoperative following a total bilateralmastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?
A. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds
B. Providing the client with information on community resources that will strengthen her coping skills
C. Identifying the client's perception of the changes in her physical appearance
Identifying the client's perception of the changes in her physical appearance is essential for developing a plan of care that addresses her psychosocial needs and promotes her self-esteem and body image. The client may experience grief, anger, depression, anxiety, or guilt after losing her breasts, which can affect her quality of life and recovery. The nurse should explore how the client feels about herself and her sexuality, and provide emotional support and empathy. The other actions are also important, but they are not as a priority as understanding how the client views herself.
D. Encouraging the client to write about her feelings in a journal each day
Full Explanation
The correct answer is C. Identifying the client's perception of the changes in her physical appearance is essential for developing a plan of care that addresses her psychosocial needs and promotes her self-esteem and body image. The client may experience grief, anger, depression, anxiety, or guilt after losing her breasts, which can affect her quality of life and recovery. The nurse should explore how the client feels about herself and her sexuality, and provide emotional support and empathy. The other actions are also important, but they are not as a priority as understanding how the client views herself.