Question

A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (Select all that apply.)

Answer 1

Correct Answers:

Lochia serosa
Fundus displaced to the right

Rationale :

🩸Lochia serosa is expected around day 4 postpartum, showing normal progression from lochia rubra.

📉The fundus normally descends about 1 cm per day, making 4 cm below the umbilicus appropriate at this stage.

⚠️A foul odor suggests infection (endometritis), which is abnormal.

📍A fundus displaced to the right indicates a full bladder, not a normal finding.

📌Core Message

Normal postpartum findings include lochia progression and steady fundal descent, while odor or displacement signals complications.

Answer 2

Correct Answers

Assess for urinary retention. [ Essential ]
Assist the client with ambulation. [ Contraindicated ]
Inform the client to expect drowsiness. [ Essential ]
Monitor for elevated temperature. [ Essential ]
Encourage the client to turn from side to side. [ Essential ]

Rationale :

💉Epidural anesthesia can block bladder sensation leading to urinary retention, so assessment is necessary.

🚫Ambulation is unsafe immediately after epidural due to decreased motor function and risk of falls, making it contraindicated.

😴Clients often experience drowsiness from anesthesia, so education prepares them and promotes safety.

🌡️Monitoring temperature is important because epidurals can be associated with maternal fever or infection.

📌Core Message

Epidural care requires monitoring for complications and preventing injury, especially avoiding unsafe ambulation.

Answer 3

Correct Answers:

Flush the tubing with 30 mL of water every 4 hr.

Rationale :

💧Regular flushing prevents tube occlusion and maintains patency of the feeding system.

🦠Open systems have a higher risk of bacterial contamination, so frequent maintenance is required.

⏱️Checking gastric residual should occur every 4–6 hr, not every 12 hr.

🛏️The head of bed should be elevated to 30–45° to prevent aspiration, not 20°.

📌Core Message

Proper care of enteral feeding requires frequent flushing and maintaining tube patency to avoid complications.

Answer 4

Correct Answers

Client 4 [ Never Event ]
Client 5 [ Near Miss ]
Client 2 [ Near Miss ]
Client 1 [ Near Miss ]
Client 3 [ Never Event ]

Rationale :

🚨A never event involves actual client harm, such as IV infiltration causing tissue damage.

🧪Delayed catheter removal led to infection, which is a preventable adverse event.

⚠️A near miss occurs when an error is caught before reaching the client or causing harm.

🛑Examples include wrong consent identified early and allergy caught before medication administration.

📌Core Message

A never event causes harm, while a near miss is intercepted before injury occurs.

Answer 5

Correct Answers:

Request visitors perform hand hygiene prior to entering a client's room.

Rationale :

🧼Hand hygiene is the most effective way to prevent healthcare-associated infections.

👥Visitors can transmit pathogens, so proper hygiene reduces infection spread.

🚫RSV requires contact precautions, not airborne precautions.

🛏️Placing linens on the floor increases environmental contamination.

📌Core Message

Hand hygiene is the most important measure for preventing infection transmission.

Answer 6

Correct Answers:

Assign the child to an airborne infection isolation room.

Rationale :

🌬️Varicella spreads via airborne transmission, requiring isolation precautions.

🏥A negative pressure room prevents spread to others.

🚫Aspirin use increases risk of Reye’s syndrome in children.

👶Koplik spots are associated with measles, not varicella.

📌Core Message

Airborne precautions are required for infections transmitted via air particles like varicella.

Answer 7

Correct Answers:

Perform postmortem care.

Rationale :

🛏️Postmortem care is a non-invasive task appropriate for assistive personnel.

🚫NG tube removal requires clinical judgment and should be done by a nurse.

🫁Suctioning a new tracheostomy is a high-risk sterile procedure.

💉Central line dressing changes require sterile technique and nursing skill.

📌Core Message

Assistive personnel should perform routine, non-invasive tasks, while nurses handle complex procedures.

Answer 8

Correct Answers:

Cover the scale with a warmed blanket before weighing the baby.

Rationale :

🌡️Conduction heat loss occurs when a newborn comes into contact with cold surfaces, such as an unprepared scale.

🛏️Placing a warmed barrier (blanket) prevents direct transfer of heat from the infant to the colder surface.

👶Newborns are highly vulnerable due to immature thermoregulation, making prevention critical immediately after birth.

🔥This intervention specifically targets direct contact heat loss, distinguishing it from convection or evaporation.

📌Core Message

Prevent heat loss by conduction by avoiding direct contact with cold objects using warming barriers.

Answer 9

Correct Answers:

"Have your child drink a small glass of water after swallowing the medication."

Rationale :

💊Digoxin should be administered carefully to ensure accurate dosing and absorption.

🚫Mixing with large volumes (like juice) risks incomplete ingestion, reducing effectiveness.

💧A small amount of water helps ensure the medication is fully swallowed without altering absorption.

⚠️Proper administration prevents toxicity or subtherapeutic levels, both dangerous in heart failure.

📌Core Message

Ensure accurate digoxin dosing by giving it properly and avoiding mixing with large fluids.

Answer 10

Correct Answers:

Sit at or below the client's eye level during feedings.

Rationale :

🧠Clients with dysphagia require safe swallowing positioning to prevent aspiration.

👀Sitting at or below eye level allows the nurse to observe swallowing effectively.

🪑This promotes client control and proper posture, reducing choking risk.

🚫Other actions like chin lifting or talking may increase aspiration risk.

📌Core Message

Proper feeding position enhances safety and reduces aspiration risk in dysphagia.

Nursing Action	Essential	Contraindicated
Assess for urinary retention.
Assist the client with ambulation.
Inform the client to expect drowsiness.
Monitor for elevated temperature.
Encourage the client to turn from side to side.

Client Report	Never Event	Near Miss
Client 4
Client 5
Client 2
Client 1
Client 3

1 :
A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (Select all that apply.)

2 :
A nurse is caring for a patient.

Correct Answers

3 :
A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following interventions should the nurse include in the plan of care?

4 :
A nurse is reviewing incident reports about clients who experienced unexpected events.

Correct Answers

5 :
An infection control nurse is providing teaching about infection control measures to a group of staff nurses. Which of the following information should the nurse include?

6 :
A nurse is preparing to admit a 6-year-old child who has varicella to a pediatric unit. Which of the following actions should the nurse take?

7 :
A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

8 :
A nurse is performing an initial assessment of a newborn. Which of the following actions should the nurse take to prevent any heat loss through conduction?

9 :
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

10 :
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

1 : A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (Select all that apply.)

2 : A nurse is caring for a patient.

Correct Answers

3 : A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following interventions should the nurse include in the plan of care?

4 : A nurse is reviewing incident reports about clients who experienced unexpected events.

Correct Answers

5 : An infection control nurse is providing teaching about infection control measures to a group of staff nurses. Which of the following information should the nurse include?

6 : A nurse is preparing to admit a 6-year-old child who has varicella to a pediatric unit. Which of the following actions should the nurse take?

7 : A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

8 : A nurse is performing an initial assessment of a newborn. Which of the following actions should the nurse take to prevent any heat loss through conduction?

9 : A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

10 : A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?

1 :
A nurse is caring for a client who is 4 days postpartum. Which of the following assessment findings should the nurse expect? (Select all that apply.)

2 :
A nurse is caring for a patient.

3 :
A nurse is planning care for a client who is receiving continuous enteral tube feedings through an open system. Which of the following interventions should the nurse include in the plan of care?

4 :
A nurse is reviewing incident reports about clients who experienced unexpected events.

5 :
An infection control nurse is providing teaching about infection control measures to a group of staff nurses. Which of the following information should the nurse include?

6 :
A nurse is preparing to admit a 6-year-old child who has varicella to a pediatric unit. Which of the following actions should the nurse take?

7 :
A nurse is assigning tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

8 :
A nurse is performing an initial assessment of a newborn. Which of the following actions should the nurse take to prevent any heat loss through conduction?

9 :
A nurse is providing teaching about digoxin administration to the parents of a toddler who has heart failure. Which of the following statements should the nurse include in the teaching?

10 :
A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?