A nurse is talking with the parents of a 2-month-old infant who have chosen to not immunize the infant. Which of the following responses should the nurse make?

Your baby’s immunizations should be up to date before they are able to travel with you by airplane.

The provider can give you a referral for your baby to see an infectious disease provider.

You don’t have to immunize your baby against diseases that are no longer common.

Let’s talk about what you already know about immunizing your baby.

Answer and Explanation

The Correct Answer is D

Choice A reason: Stating immunizations are required for air travel is inaccurate, as no such mandate exists for infants. This response does not address the parents’ concerns or educate them, potentially alienating them, making it ineffective and incorrect for fostering dialogue about immunization.
Choice B reason: Offering a referral to an infectious disease provider is premature and does not directly address the parents’ decision. Education and discussion are needed first to understand their concerns, making this response less effective and inappropriate as an initial approach.
Choice C reason: Suggesting no need to immunize against rare diseases is misleading, as vaccines prevent resurgences (e.g., measles). This undermines public health and dismisses the parents’ concerns, making it incorrect and potentially harmful to the infant’s health.
Choice D reason: Inviting discussion about the parents’ knowledge fosters open, non-judgmental communication, allowing the nurse to address misconceptions and provide evidence-based information. This therapeutic approach builds trust and encourages informed decision-making, making it the correct response for vaccine hesitancy.

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Correct Answer is D

Explanation

Choice A reason: Giving 2 ounces of water before newborn genetic screening is unnecessary and inappropriate, as the test involves a heel stick blood sample, not oral intake. Water may disrupt feeding or hydration balance in newborns, making this statement incorrect and irrelevant.
Choice B reason: Newborn genetic screening is typically a one-time test shortly after birth, not repeated at 2 months unless specific conditions warrant follow-up. Routine repetition is not standard, making this statement inaccurate for general teaching about the screening process.
Choice C reason: Blood for newborn genetic screening is collected via a heel stick, not the inner elbow, to minimize discomfort and obtain sufficient capillary blood. Drawing from the elbow is incorrect and impractical for newborns, making this statement inaccurate.
Choice D reason: Performing genetic screening after 24 hours ensures accurate detection of metabolic disorders, as newborns need time to metabolize nutrients. This timing aligns with national guidelines (e.g., AAP), making it essential and correct information for parents about the screening process.

A. Check the system for patency every 8 hours. B. Empty the drainage system every 24 hours. C. Secure the drainage system to the client’s gown. D. Replace the drainage system every 3 days.

Correct Answer is C

Explanation

Choice A reason: Checking patency every 8 hours is inadequate for closed wound drainage systems, which require more frequent monitoring (e.g., every 4 hours) to detect blockages. Delayed checks risk fluid buildup, increasing infection or seroma risk, critical in postoperative wound management.
Choice B reason: Emptying the drainage system every 24 hours may be insufficient, as frequency depends on volume. Systems like Jackson-Pratt drains need emptying when half-full to maintain suction, preventing complications like infection, requiring flexible, volume-based schedules rather than fixed intervals.
Choice C reason: Securing the drainage system to the gown prevents dislodgement, maintaining suction and reducing infection risk. It supports mobility while stabilizing the system, preventing wound tension. This is critical for effective drainage and healing in postoperative clients with closed systems.
Choice D reason: Replacing the drainage system every 3 days is unnecessary unless infection or malfunction occurs. Routine replacement risks introducing pathogens or disrupting healing. Systems remain until drainage decreases, guided by clinical assessment, not a fixed schedule, to ensure safety.

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A nurse is talking with the parents of a 2-month-old infant who have chosen to not immunize the infant. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to the parents of a newborn about newborn genetic screening. Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is caring for a client who has a closed wound drainage system. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. Which of the following actions taken by the AP indicates proper technique for urinary catheter care?

A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is developing a plan of care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following actions should the nurse include in the plan?

A nurse is assisting a client who lives in a rural community with obtaining health services. Which of the following actions by the nurse demonstrates coordination of care?

A charge nurse is teaching new staff members about factors that increase a client’s risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

A nurse is providing teaching to a parent of a child who has Varicella. Which of the following statements should the nurse include in the teaching?

A nurse is planning care for a male client who is postoperative following a hernia repair. Which of the following actions should the nurse include in the plan?