A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?

Correct Answer: B

Rationale: Clinging reflects normal separation anxiety at this age, reassuring the parent.

Correct Answer: C

Rationale: Fowler's position, where the head of the bed is elevated, is ideal for patients with breathing difficulties because it maximizes lung expansion and eases respiratory effort. Gravity assists the diaphragm's movement, reducing pressure on the chest and improving oxygen intake, which is critical in conditions like dyspnea. Prone position (lying face down) may help specific cases like ARDS but isn't generally recommended for most breathing issues. Supine position (flat on back) can restrict lung expansion, worsening the problem. Trendelenburg position (head lower than feet) is used for circulatory issues, not respiratory support, and could exacerbate breathing difficulties. Fowler's position aligns with physiological needs for better air exchange, making it the nurse's go-to choice.

Correct Answer: C

Rationale: Elderly individuals with limited mobility are at higher risk for pressure ulcers due to age-related skin thinning, reduced circulation, and prolonged pressure on bony areas from immobility. These factors impair skin integrity, making it prone to breakdown. Young adults typically have resilient skin and mobility, lowering their risk. Athletes, with strong circulation and muscle tone, are less susceptible unless injured. Regular exercisers maintain healthy blood flow, reducing risk further. The elderly, especially when bedridden or chair-bound, face constant pressure and shear forces, compounded by potential malnutrition or chronic illness, necessitating vigilant nursing care like repositioning and pressure-relieving devices.

Correct Answer: C

Rationale: Washing hands with soap and water for at least 20 seconds (ideally 40-60 per CDC guidelines) before and after patient care removes pathogens effectively, breaking the chain of infection. Wiping on a towel doesn't kill germs and may spread them. Using sanitizer only after care skips pre-care protection, risking contamination to the patient soap is superior for visible dirt or C. diff. Shaking hands for rapport, while friendly, isn't hygiene-focused and could transmit microbes. This rigorous washing is a fundamental nursing practice, safeguarding both patient and nurse from healthcare-associated infections.

Correct Answer: B

Rationale: A urinary catheter's primary purpose is to collect urine for analysis or drainage when a patient can't void naturally, aiding diagnosis or relieving retention. Medication administration isn't its role IVs or oral routes handle that. Blood pressure measurement uses cuffs, not catheters. Breathing assistance relates to respiratory devices, not urinary ones. Nurses insert catheters to monitor output, assess kidney function, or manage incontinence, making urine collection the core function in clinical practice, critical for patient assessment and care planning.