a nurse is providing discharge instructions to parents of a circumcised newborn to prevent diaper adherence to the penis what will be recommended to a
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Nursing Elites

ATI LPN

PN ATI Capstone Maternal Newborn

1. A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?

Correct answer: C

Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals. Baby oil (Choice A) is not recommended as it may not provide a sufficient barrier to prevent adherence. Antibiotic ointment (Choice B) is not typically used for this purpose and can sometimes cause irritation. Alcohol wipes (Choice D) are too harsh for the sensitive skin of a newborn and can cause irritation.

2. A nurse is preparing to teach a client with chronic renal failure. Which dietary instruction is most appropriate?

Correct answer: D

Rationale: The correct answer is to restrict protein intake for a client with chronic renal failure. In renal failure, the kidneys are unable to effectively filter waste products. Excessive protein intake can lead to the accumulation of waste products, increasing the workload on the kidneys. Therefore, restricting protein intake is essential to prevent further kidney damage. Choices A, B, and C are incorrect. Increasing calcium intake is not specifically indicated for chronic renal failure. Increasing potassium intake can be dangerous in renal failure as impaired kidneys may not be able to excrete excess potassium. Increasing protein intake is contraindicated in chronic renal failure as it can worsen kidney function and increase the accumulation of waste products.

3. A nurse is caring for a client who has liver cirrhosis and ascites. Which of the following actions should the nurse take to monitor the effectiveness of the treatment?

Correct answer: A

Rationale: Measuring the client’s abdominal girth daily is the most effective way to monitor the reduction of ascites and fluid retention in clients with liver cirrhosis. This measurement helps assess the effectiveness of treatment in managing ascites by monitoring changes in abdominal size. Monitoring the client’s hemoglobin level (Choice B) is not directly related to assessing the effectiveness of ascites treatment. Administering lactulose as prescribed (Choice C) is important in managing hepatic encephalopathy, not ascites. Weighing the client weekly (Choice D) may not provide real-time feedback on the reduction of ascites compared to daily abdominal girth measurements.

4. A community health nurse is reviewing primary prevention for West Nile virus with a group of patients in a rural health clinic. What instructions should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'Eliminate areas of standing water.' Standing water provides breeding grounds for mosquitoes, which spread West Nile virus. By eliminating standing water, individuals can reduce the risk of mosquito breeding and the transmission of the virus. Choices B, C, and D are incorrect. Wearing a mask when outdoors, ensuring food is cooked thoroughly, and avoiding contact with sick individuals are not directly related to primary prevention strategies for West Nile virus.

5. A nurse is caring for a client who has end-stage osteoporosis and is reporting severe pain. The client’s respiratory rate is 14 per minute. Which of the following medications should the nurse prioritize administering?

Correct answer: B

Rationale: Hydromorphone, an opioid, is the most appropriate option for managing severe pain in this context. Opioids provide fast-acting relief for acute pain associated with advanced osteoporosis. Promethazine (Choice A) is an antihistamine and not indicated for pain relief. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may increase the risk of bleeding and is not recommended for severe pain management. Amitriptyline (Choice D) is a tricyclic antidepressant that is not the first-line treatment for severe acute pain.

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