The nurse is providing instructions to the client regarding cord care. Which of the following statements, if made by the client, indicates a need for further education?
1. "Alcohol may be used if prescribed to clean the cord."
2. "The cord will fall off in 1 to 2 weeks."
3. "I should clean the cord two or three times a day."
4. "I need to fold the diaper above the cord to prevent infection."
4
Rationale: The cord should be kept clean and dry to decrease bacterial growth. The diaper should be folded below the cord to keep urine away from the cord. The cord should be cleaned two or three times a day using alcohol or other prescribed solution. Cord care is required until the cord dries up and falls off, usually between 7 and 14 days postpartum.
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A patient with acute mania has disrobed in the hall 3 times in 2 hours. The nurse should:
a. direct the patient to wear clothes at all times. b. tell the patient that others feel embarrassed. c. provide a hospital gown for the patient. d. arrange one-on-one supervision.
Which step is appropriate when using EMLA cream before intravenous catheter insertion?
a. Rub a liberal amount of cream into the skin thoroughly. b. Cover the skin with a gauze dressing after applying the cream. c. Leave the cream on the skin for 1 to 2 hours before the procedure. d. Use the smallest amount of cream necessary to numb the skin surface.
An infant has been diagnosed as having congenital hypothyroidism. L-thyroxine is ordered for the infant. The infant is being bottle-fed
Why will the nurse who is working with this child and family instruct the caregivers to avoid formulas that are soy-based and provide the family with a list of soy-based formulas? a. L-thyroxine's absorption is affected by formulas that are soy based. b. Children who are on L-thyroxine and soy-based formulas often have allergic reactions. c. The L-thyroxine interferes with the absorption of calcium in the soy formula. d. Infants on soy formula and L-thyroxine will tend to vomit the formula.
A nurse enters the room of a patient newly diagnosed with multiple sclerosis and notes that the patient is crying quietly while lying in bed. Which communication by the nurse would be most appropriate?
a. "You are crying. What are you feeling that's making you so sad?" b. "Do you want me to call the health care provider to order some antidepressant medication for you?" c. "I can understand why you would cry. I imagine most people would feel sad after being given your diagnosis.". d. "Crying is a normal response to a diagnosis such as yours. You'll feel better after your plan of care has been fully developed.".