A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?

Encourage the toddler to flush the toilet while still seated.

Have the toddler remain on the toilet for a minimum of 20 min.

Wake the toddler every 2 hr. in the night to prevent bed-wetting.

Give the toddler a sticker after each successful toileting attempt.

Answer and Explanation

The Correct Answer is D

A. Encouraging the toddler to flush the toilet while still seated is incorrect. Some children may be startled by the flushing sound, which can create fear and resistance to toilet training. It is better to allow the child to stand before flushing if they show hesitation.

B. Having the toddler remain on the toilet for a minimum of 20 minutes is incorrect. Extended sitting can lead to discomfort and frustration, making the experience negative. Shorter, 5- to 10-minute sessions are more effective and developmentally appropriate.

C. Waking the toddler every 2 hours in the night to prevent bed-wetting is incorrect. Nighttime bladder control develops gradually, and disrupting sleep can be counterproductive. Instead, using protective bedding and encouraging toileting before bedtime is recommended.

D. Giving the toddler a sticker after each successful toileting attempt is correct. Positive reinforcement, such as stickers or praise, encourages consistency and motivation, which is particularly beneficial for children with cognitive impairments.

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Correct Answer is D

Explanation

A. Administering a subcutaneous insulin injection requires nursing knowledge and skill to ensure correct dosage, technique, and monitoring for side effects. This should not be delegated to an assistive personnel (AP).

B. Removing an NG tube requires nursing assessment to determine if removal is appropriate and safe for the client. It also requires skill in managing complications that may arise. This should not be delegated to an AP.

C. Providing discharge teaching about home IV medication therapy is a complex task that requires nursing knowledge about medication management, potential complications, and instructions for safe administration. It cannot be delegated to an AP.

D. Collecting a sputum culture can be delegated to an AP. This is a task within their scope of practice, provided the AP has been trained in collecting samples and the procedure is straightforward.

A. Wear sterile gloves when in contact with body fluids. B. Use alcohol-based cleanser when hands are visibly soiled. C. Wash hands with soap and water for 20 seconds. D. Artificial nails can be worn when performing direct client care.

Correct Answer is C

Explanation

A. "Wear sterile gloves when in contact with body fluids" is incorrect. While sterile gloves are necessary for sterile procedures, clean gloves are generally sufficient for contact with body fluids. The main focus of hand hygiene is on proper handwashing techniques.

B. "Use alcohol-based cleanser when hands are visibly soiled" is incorrect. Alcohol-based hand sanitizers should not be used when hands are visibly soiled, as they are less effective in removing dirt, grease, or organic material. Soap and water are needed for visibly soiled hands.

C. "Wash hands with soap and water for 20 seconds" is correct. The recommended duration for handwashing is 20 seconds, which is sufficient for removing pathogens effectively. This is standard practice for maintaining proper hand hygiene in healthcare settings.

D. "Artificial nails can be worn when performing direct client care" is incorrect. Artificial nails and chipped nail polish are contraindicated in healthcare settings because they can harbor bacteria and increase the risk of infection transmission.

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A nurse is reinforcing teaching about toilet training with the guardians of a toddler who has a cognitive impairment. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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