Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The nurse is teaching parents how to care for their son’s circumcision site after discharge from hospital using petroleum jelly and gauze dressing method.
Which statement by parents indicates that they need further instruction?
A. “We will change his diaper every 3 to 4 hours.”
Changing the diaper every 3 to 4 hours is recommended to prevent infection and keep the area clean and dry.
B. “We will wash his penis with soap and water daily.”
Washing the penis with soap and water daily can irritate the circumcision site and delay healing. The parents should only use warm water to gently clean the area and pat it dry. They should avoid using soap, alcohol, or peroxide on the wound.
C. “We will apply petroleum jelly on his penis with each diaper change.”
Applying petroleum jelly on the penis with each diaper change can protect the wound from sticking to the diaper and reduce friction.
D. “We will call his doctor if we see any signs of infection.”
Calling the doctor if they see any signs of infection, such as redness, swelling, pus, foul odor, or fever, is a correct action.
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Full Explanation
The correct answer is choice B. Washing the penis with soap and water daily can irritate the circumcision site and delay healing.
The parents should only use warm water to gently clean the area and pat it dry.
They should avoid using soap, alcohol, or peroxide on the wound.
Choice A is wrong because changing the diaper every 3 to 4 hours is recommended to prevent infection and keep the area clean and dry.
Choice C is wrong because applying petroleum jelly on the penis with each diaper change can protect the wound from sticking to the diaper and reduce friction.
Choice D is wrong because calling the doctor if they see any signs of infection, such as redness, swelling, pus, foul odor, or fever, is a correct action.
Similar Questions
The nurse is caring for a newborn who was circumcised using a Gomco clamp 12 hours ago and notes that there is a small amount of blood on his diaper where his penis rests against it.
The most appropriate nursing action would be to:
A. Apply gentle pressure to stop bleeding
Applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.
B. Change his diaper more frequently
Changing the diaper more frequently may also disturb the healing process and increase the risk of infection.
C. Document this as a normal finding
Document this as a normal finding.According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place. Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.
D. Notify his physician
Notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.
Full Explanation
The correct answer is choice C. Document this as a normal finding. According to the American Academy of Family Physicians, bleeding from the dorsal slit after circumcision using a Gomco clamp is usually minimal and will stop once the clamp is in place.
Therefore, a small amount of blood on the diaper 12 hours after the procedure is not a cause for concern and does not require any intervention.
Choice A is wrong because applying gentle pressure to stop bleeding is not necessary and may cause more trauma to the wound.
Choice B is wrong because changing the diaper more frequently may also disturb the healing process and increase the risk of infection. Choice D is wrong because notifying the physician is not indicated unless there is excessive or persistent bleeding, signs of infection, or other complications.
A postpartum nurse instructs a new mother in how to bathe her newborn.
Which statement by the mother indicates a need for further instruction?
A. “I should use a clean cloth and warm water to wash around the umbilical cord.”
It is correct to use a clean cloth and warm water to wash around the umbilical cord.This helps prevent infection and promotes drying of the cord stump.
B. “I should bathe him before a feeding so he won’t spit up.”
This statement indicates a need for further instruction because it is not advisable to bathe a newborn infant before a feeding, as this may cause hypoglycemia or cold stress.The mother should bathe the infant after a feeding or between feedings when the infant is alert and comfortable.
C. “I should avoid getting water in his ears or eyes.”
It is correct to avoid getting water in the infant’s ears or eyes.This helps prevent ear infections and eye irritation.
D. “I should avoid getting water in his ears or eyes.”
It is correct to dry the infant thoroughly and dress him warmly after bathing. This helps prevent heat loss
Full Explanation
The correct answer is choice B. “I should bathe him before a feeding so he won’t spit up.” This statement indicates a need for further instruction because it is not advisable to bathe a newborn infant before a feeding, as this may cause hypoglycemia or cold stress. The mother should bathe the infant after a feeding or between feedings when the infant is alert and comfortable.
Choice A is wrong because it is correct to use a clean cloth and warm water to wash around the umbilical cord. This helps prevent infection and promotes drying of the cord stump.
Choice C is wrong because it is correct to avoid getting water in the infant’s ears or eyes. This helps prevent ear infections and eye irritation.
Choice D is wrong because it is correct to dry the infant thoroughly and dress him warmly after bathing.
This helps prevent heat loss
A nurse is educating a new mother about umbilical cord care and how to prevent omphalitis, sepsis, and tetanus.
Which of the following statements by the mother indicates an understanding of the teaching?
A. “I should wash my hands before and after handling the cord stump.”
Washing hands before and after handling the cord stump can prevent the transmission of bacteria that can cause omphalitis, sepsis, and tetanus.
B. “I should apply petroleum jelly or ointment to the cord stump after each diaper change.”
Applying petroleum jelly or ointment to the cord stump can delay its drying and increase the risk of infection.
C. “I should use a cotton swab dipped in hydrogen peroxide to clean around the base of the cord stump.”
Using hydrogen peroxide to clean the cord stump can damage the healthy tissue and delay healing.
D. “I should fold down the top of the diaper below the cord stump until it falls off.”
Folding down the diaper below the cord stump can expose it to urine and feces, which can contaminate it and cause infection.
Full Explanation
The correct answer is choice A. Washing hands before and after handling the cord stump can prevent the transmission of bacteria that can cause omphalitis, sepsis, and tetanus.
Choice B is wrong because applying petroleum jelly or ointment to the cord stump can delay its drying and increase the risk of infection.
Choice C is wrong because using hydrogen peroxide to clean the cord stump can damage the healthy tissue and delay healing.
Choice D is wrong because folding down the diaper below the cord stump can expose it to urine and feces, which can contaminate it and cause infection.
The normal range for umbilical cord separation is 5 to 15 days after birth.