A nurse is reinforcing teaching with the parents of a newborn about bathing. Which of the following instructions should the nurse include in the teaching?

"Check the water temperature with your finger"

"Hold your baby under running water when washing his hair,"

"Cleanse the eyes from the inner canthus outward.

"Set the water heater to 125.6 degrees Fahrenheit."

Answer and Explanation

The Correct Answer is C

A. "Check the water temperature with your finger": Checking water temperature with a finger is unreliable because fingers may tolerate higher temperatures without discomfort. It is recommended to use the inside of the wrist or a thermometer to ensure the water is warm but not hot, typically around 100°F (37.8°C), to prevent burns.

B. "Hold your baby under running water when washing his hair": Holding a newborn under running water is unsafe because it can cause sudden chilling, difficulty breathing, or even slipping. Instead, caregivers should use a damp, warm washcloth or gently pour water over the baby's head while securely supporting it.

C. "Cleanse the eyes from the inner canthus outward": Cleaning from the inner to the outer canthus is correct technique because it prevents introducing contaminants into the tear duct. This motion also minimizes the spread of bacteria, reducing the risk of eye infections in the delicate eyes of a newborn.

D. "Set the water heater to 125.6 degrees Fahrenheit": A water heater set to 125.6°F presents a high risk of scald burns in infants. Safety guidelines recommend setting the water heater to no higher than 120°F (48.9°C) to reduce the risk of accidental burns during bathing or household water use.

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Correct Answer is A

Explanation

A: Image A shows hands with fingers that appear elongated and have widened nail beds. The fingertips look rounded and bulbous, which is characteristic of clubbing. Clubbing often results from chronic hypoxia and is seen in conditions like congenital heart disease, cystic fibrosis, and chronic lung disease.

B: Image B shows normal-appearing fingers with straight nail beds and no signs of bulbous enlargement at the fingertips. This appearance is not consistent with clubbing and represents normal finger structure without signs of chronic hypoxia or circulatory issues.

A. Review the need for the indwelling urinary catheter daily B. Empty the drainage bag when it is half full C. Use soap and water to provide perineal care D. Place the drainage bag on the bed when transporting the client E. Encourage the client to drink 1000 ml of fluid daily F. Change the indwelling urinary catheter tubing every 3 days.

Correct Answer is ["A","C"]

Explanation

A. Review the need for the indwelling urinary catheter daily: Daily review of catheter necessity reduces the risk of catheter-associated urinary tract infections (CAUTIs). Prompt removal when no longer needed limits bacterial entry and colonization, which significantly lowers infection rates in hospitalized clients.

B. Empty the drainage bag when it is half full: The drainage bag should be emptied when it is about two-thirds full, not half full, to prevent backflow and reduce strain on the system. Emptying too early or too often increases the risk of introducing pathogens into the closed system.

C. Use soap and water to provide perineal care: Using soap and water for perineal hygiene maintains cleanliness and reduces bacterial colonization near the catheter site. Routine perineal care is a critical intervention to minimize the risk of ascending infections into the urinary tract.

D. Place the drainage bag on the bed when transporting the client: The drainage bag must remain below bladder level during transport to prevent backflow of urine into the bladder. Placing the bag on the bed risks contamination and promotes reflux of potentially infected urine.

E. Encourage the client to drink 1000 mL of fluid daily: Although hydration generally helps prevent UTIs, this client is on a strict 1000 mL fluid restriction due to heart failure. Encouraging more fluid intake could worsen fluid overload and does not align with current prescribed therapy.

F. Change the indwelling urinary catheter tubing every 3 days: Routine changing of catheter tubing is not recommended unless clinically indicated (e.g., contamination, obstruction, infection). Unnecessary manipulation increases the risk of introducing pathogens into the urinary system.

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A nurse is reinforcing teaching with the parents of a newborn about bathing. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

Correct Answer is A

Explanation

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Correct Answer is ["A","C"]

Explanation

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