A nurse is teaching parents how care for their newborn. Which of the following
statements indicates a good understanding of how to use a bulb syringe to suction
excess mucous from the infant’s airway?
Select one:
a. “The bulb syringe should be sterilized after each use.”
b. “I should suction my baby’s mouth before the nose.”
CORRECT. The mouth should always be suctioned before the nose to prevent aspiration during the gasp
response that occurs when the nose is suctioned.
c. “The bulb syringe should reach to the back of my baby’s throat.”
d. “I should compress the bulb syringe after I place it in my baby’s mouth.”
The parent of a two-year-old child reports feeling frustrated with the fact that her son is
saying no to everything. The nurse should teach the parent that this behavior is a
normal expression of the child’s desire to accomplish which of the following?
Select one:
a. Increase their independence.
CORRECT. The drive for independence is expressed by the toddler opposing the desires of those in authority
(tantrums) and attempting to do everything for themselves. The Erickson developmental stage for this age is
“Autonomy vs. Shame and Doubt.”
b. Finish a project they set out to do.
c. Develop their sense of trust.
d. Gratify their oral fixation.
At a well-child visit, the parents report that their toddler occasionally touches and
fondles her genital area. The parents ask the nurse if this behavior is something to be
concerned about. Which of the following is a correct response?
Select one:
a. This is a possible infection or irritation in the genital area
b. This is an early emergence of sexual expression that should be discouraged
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,c. Awareness of body structures and sensations is normal and expected
CORRECT. Genital self-stimulation by the toddler is normal and expected. It is a new area to explore, similar
to exploring the toes at an earlier age, but it has pleasurable sensations too! It should be ignored unless the
behavior becomes pervasive, and then it should still be ignored and the child should be distracted to come
and do some fun and exciting activity
d. Your child is probably imitating behaviors that she has observed
A nurse is completing a dietary evaluation for a client diagnosed with acute
glomerulonephritis. Which of the following statements made by the client demonstrates
understanding of necessary restrictions?
Select one:
a. “I should limit my sodium intake to 4 grams per day.”
CORRECT. Excessively high protein and sodium diets put clients at risk for glomerulonephritis. Clients with
this condition should implement sodium and protein restriction.
b. “I should increase my consumption of protein.”
c. “I should consume a diet low in carbohydrates.”
d. “I should increase my fluid intake to 8-10 glasses of water a day.”
A nurse is assisting a client with bowel training. When should the nurse instruct the
client to attempt defecation?
Select one:
a. Immediately before meals.
b. Every hour while awake.
c. When the client has the urge to defecate.
CORRECT. Failure to heed the call to defecate may lead to overdistention of the rectum with hardening of the
stool and subsequent constipation. Therefore, the best time to toilet a client to encourage bowel training is
when the client has the urge to defecate.
d. When the client feels abdominal cramping.
A nurse is calculating the client’s intake and output. Based on the information below,
which of the following values correctly represents the client’s total output?
• Sipped 8 oz. clear broth.
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, • 100 mL ice chips.
• Voided 450 mL.
• IV push pain medication 50 mL.
• Drank 4 oz. juice and 6 oz. hot tea.
• Vomited 120 mL and voided 600 mL.
• Jackson Pratt drain emptied 40
mL. Select one:
a. 590 mL
b. 1068 mL
c. 680 mL
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