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Question 1 of 5

A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?

Correct Answer: C

Rationale: The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.

Question 2 of 5

The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?

Correct Answer: A,C,D,E

Rationale: TLS causes hyperkalemia (
C), hyperuricemia (
D), and mental changes (E) due to electrolyte imbalances and low blood pressure (
A) from fluid shifts. Hyperactivity (
B) is not typical.

Question 3 of 5

The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:

Correct Answer: C

Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.

Question 4 of 5

The nurse is teaching a client with a history of atrial fibrillation about medication adherence. The nurse should tell the client to:

Correct Answer: A

Rationale: Anticoagulants reduce stroke risk in atrial fibrillation, so adherence is critical.

Question 5 of 5

A client requires log rolling after back surgery. Correctly provide the sequence of steps the nurse should follow when performing the procedure.

Order the Items

Source Container

Obtain assistance; three nurses are preferable.
Maintain client's position in alignment with pillows.
Position two nurses on the side the client will be turned to and the third nurse on the opposite side of the bed.
Designate the person at the head of the bed to be in charge of coordinating the move.
Place a pillow between the client's knees.
Move the client in one coordinated movement when the nurse at the head of the bed signals to move the client.
Instruct the client to place the arms across the chest.

Correct Answer: A, C, D, G, E, B, F

Rationale: Log rolling sequence: Obtain assistance (
A), position nurses (
C), designate leader (
D), instruct arm placement (G), place pillow (E), align with pillows (
B), move coordinately (F).

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