Nokea
Nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. The nurse indicates understanding when she states that which are manifestations of systemic infection? (Select all that apply.)
- A. Fever
- B. Malaise
- C. Edema
- D. Pain/tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A,B,E
Rationale: The correct answer is A, B, and E. Fever is a hallmark sign of a systemic infection as the body's response to infection. Malaise, a general feeling of discomfort, is also common in systemic infections due to the body's immune response. An increase in pulse and respiratory rate occurs in systemic infections as the body tries to combat the infection. Edema and pain/tenderness are more indicative of localized infections and are not typically seen in systemic infections. Therefore, choices C and D are incorrect in this context.
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By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process?
- A. Reassess client to determine reasons for unsatisfactory pain relief
- B. See whether pain lessens during next 24h
- C. Change plan to ensure client achieves adequate pain relief
- D. Teach client about plan of care for managing his pain
Correct Answer: A
Rationale: The correct answer is A. In the nursing process, the first step in addressing a client's unsatisfactory pain relief is to reassess the client to determine the reasons for it. This involves evaluating the pain intensity, location, characteristics, aggravating factors, and the client's response to current pain management interventions. By reassessing, the nurse can identify any underlying causes contributing to the lack of pain relief and adjust the plan of care accordingly.
Choice B is incorrect because waiting another 24 hours without further assessment delays appropriate intervention. Choice C is incorrect as changing the plan without reassessment may not address the root cause of the issue. Choice D is incorrect as teaching the client about the plan of care should come after reassessment to ensure it is tailored to the client's specific needs.
A Client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse providing pre-op care regarding informed consent? (Select all that apply.)
- A. Make sure the surgeon obtained the client's consent
- B. Witness client's signature on consent form
- C. Explain the risks/benefits of procedure
- D. Describe consequences of choosing not to have surgery
- E. Tell client about alternatives to having surgery
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: Making sure the surgeon obtained the client's consent is crucial to ensure that the client has been properly informed about the procedure and has willingly agreed to it.
B: Witnessing the client's signature on the consent form is important to confirm that the client understood the information provided and voluntarily agreed to the procedure.
Summary:
C: Explaining the risks/benefits of the procedure is important, but this is typically the responsibility of the healthcare provider, not the nurse providing pre-op care.
D: Describing consequences of choosing not to have surgery is important, but it is the healthcare provider's role, not the nurse's, to discuss this with the client.
E: Informing the client about alternatives to surgery is important, but the primary responsibility lies with the healthcare provider, not the nurse providing pre-op care.
Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers causing the baby's symptoms.
C: Asking about specific foods helps pinpoint if a particular food is causing the issues.
D: Inquiring about vomiting helps assess if the baby's symptoms could be due to a more serious underlying issue.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding new foods without identifying the problem isn't ideal.
E: Not all babies react with indigestion to new foods, making this statement too general and not helpful in this case.
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,
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.