Nokea
Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Requesting assistance when repositioning a client is crucial to prevent injury as it reduces the risk of strain on the nurse's body.
B: Avoiding twisting the spine or bending at the waist helps in maintaining proper body mechanics and prevents back injuries.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Summary of Incorrect Choices:
C: Keeping knees slightly lower than hips when sitting for long periods is related to ergonomics but not directly to preventing injury with client handling.
E: Taking breaks from repetitive movements every 2-3 hours is important for overall health but not specific to preventing injury with client handling.
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Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
1. Client scheduled for TURP (prostate resection): This client can be safely discharged as the procedure is elective and not urgent.
2. Client who is 24h post-op after mastectomy: This client is stable post-operation and can be discharged with appropriate follow-up care.
Summary of other choices:
A: Client who's dehydrated & receiving IV fluid/electrolytes - This client needs continued treatment and monitoring.
B: Client with NG tube to treat small bowel obstruction - This client requires ongoing treatment and observation.
E: Client scheduled for appendectomy - This client needs urgent surgical intervention and cannot be safely discharged.
Nurse is preparing in-service program about delegation. Which of following elements should she identify when presenting 5 rights of delegation? (Select all that apply.)
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. Right supervision/evaluation ensures appropriate oversight, right direction/communication is crucial for clear instructions, and right circumstances involve assessing if it is appropriate to delegate the task. Right client is not directly related to delegation, and right time is not one of the traditional 5 rights of delegation.
Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber’s signature on prescription within 24 hours
- D. Decline verbal prescription b/c it is not emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.
Incorrect Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.
When entering a client's room to change a dressing, the nurse notes the client is coughing & sneezing. When preparing a sterile field, it's important the nurse...
- A. Keep sterile field at least 6 ft away from client's bedside
- B. Instruct client to not cough/sneeze during dressing change
- C. Place mask on client to limit the spread of microorganisms into the surgical wound
- D. Keep box of Kleenex nearby for client to use during dressing change
Correct Answer: C
Rationale: The correct answer is C because placing a mask on the client helps limit the spread of microorganisms into the surgical wound. This is crucial to prevent infection. Choice A is incorrect because the distance does not necessarily prevent microorganism spread. Choice B is unrealistic as it's difficult for a client to control coughing/sneezing. Choice D does not address the prevention of microorganism spread.
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.