Nokea
Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. confidence
- B. perseverance
- C. integrity
- D. discipline
Correct Answer: D
Rationale: The correct answer is D: discipline. The nurse demonstrated discipline by following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.
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Nurse is caring for newly admitted client with history of falls. Which is priority action by nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A, complete fall-risk assessment. This is the priority action because it helps identify specific risks the client faces, allowing for tailored interventions to prevent falls. Educating the client and family (B) is important but assessing risk comes first. Completing a physical assessment (C) is also important but not the priority in this case. Surveying belongings (D) is not as urgent as assessing the client's fall risk.
Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.)
- A. Rolls from back to front
- B. Bears weight on legs
- C. Walks holding onto furniture
- D. Sits unsupported
- E. Sits down from standing position
Correct Answer: A,B,D
Rationale: The correct answer is A, B, and D. By 9 months, infants typically develop the ability to roll from back to front (choice A), bear weight on legs (choice B), and sit unsupported (choice D). Rolling from back to front demonstrates improved core strength and coordination. Bearing weight on legs indicates developing leg muscles and balance. Sitting unsupported signifies improved trunk control and balance. Choices C and E involve more advanced skills typically seen around 9-12 months. Choice C, walking holding onto furniture, is usually seen around 10-12 months, and choice E, sitting down from a standing position, typically emerges around 9-12 months.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. "I have my own apt now
- B. but it's not easy living away from my parents."
- C. It's been so stressful for me to even think about having my own family.
- D. I don't even know who I am yet, & now I'm supposed to know what to do.
- E. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.
Correct Answer: C
Rationale: The correct answer is C: "It's been so stressful for me to even think about having my own family." This is the priority issue as it indicates the young adult is struggling with the idea of starting a family, which can have long-term implications. This concern may affect their mental health, relationships, and decision-making. Option A is about independence, B about transitioning from parents, D about self-identity, and E about impending fatherhood. While important, these issues are not as urgent as the stress related to starting a family.
Nurse has removed a sterile pack from its outside cover & placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. Unfolding this flap first ensures that the sterile contents inside the pack remain protected from contamination by the nurse's body and hands. Starting with the farthest flap minimizes the risk of accidental touching or contamination of the sterile instruments or supplies. Unfolding the closest flap (choice A) or the side flaps (choices B and C) first could potentially expose the sterile contents to contamination. Therefore, unfolding the flap farthest from the body is the most appropriate and logical step to maintain sterility and ensure safe patient care during the procedure.
Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.)
- A. Family members who smoke must be at least 10 ft from client when his oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.
Incorrect Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,