Nokea
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.
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Nurse is caring for client receiving enteral tube feedings due to dysphagia. Which of following bed positions is appropriate for safe care of this client?
- A. Supine
- B. Semi-Fowler's
- C. Semi-prone
- D. Trendelenburg
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler's position. This position helps prevent aspiration during enteral tube feedings by aiding in proper digestion and reducing the risk of reflux. Semi-Fowler's position also helps facilitate optimal absorption of nutrients. Supine position (A) can increase the risk of aspiration. Semi-prone (C) and Trendelenburg (D) positions are not recommended for enteral feedings as they can lead to complications such as regurgitation and aspiration.
Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct answers are B (Varicella), C (Polio), and E (Seasonal influenza). Varicella and seasonal influenza vaccines are recommended for preschoolers by the CDC to prevent the spread of these contagious diseases. Polio vaccine is important for preventing polio, a potentially serious disease that can be prevented through vaccination. Haemophilus influenzae type b, Hepatitis A, and the other choices are not typically part of the CDC's routine immunization recommendations for preschoolers. It is crucial for the nurse to include discussions on Varicella, Polio, and Seasonal influenza vaccines to ensure the children are protected from these preventable diseases.
Nurse is preparing a discharge summary for a client who had knee surgery and is going home. Which of the following info about the client should the nurse include in it? (Select all that apply.)
- A. Advance directives status
- B. Where to go for follow-up care
- C. Instructions for diet/meds
- D. Most recent vital sign data
- E. Contact info for home healthcare agency
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Providing information on where to go for follow-up care ensures the client continues to receive proper medical attention post-surgery.
C: Instructions for diet/meds are crucial for the client's recovery and to prevent complications.
E: Providing contact info for a home healthcare agency ensures the client has access to additional support and care at home.
Incorrect answers:
A: Advance directives status is important but not directly related to immediate post-operative care.
D: Most recent vital sign data is important for monitoring but does not need to be included in a discharge summary.
Nurse caring for client who has new prescription. Prior to admin, nurse uses electronic database to gather info about med & effects it might have on this client. Which following component of critical thinking is nurse using when he reviews med info?
- A. knowledge
- B. experience
- C. intuition
- D. competence
Correct Answer: A
Rationale: The correct answer is A: knowledge. By reviewing medication information in an electronic database, the nurse is utilizing knowledge as a component of critical thinking. Knowledge involves the understanding of facts, evidence, and information relevant to the situation at hand, which in this case is understanding the medication and its potential effects on the client. This process allows the nurse to make informed decisions based on evidence and data.
Summary of incorrect choices:
B: Experience alone may not provide the detailed information about the medication's effects on the client.
C: Intuition is based on gut feelings rather than factual information from the database.
D: Competence is the ability to perform a task effectively, but it does not specifically address the gathering of information from a database for decision-making in this scenario.
Nurse admitting a client with acute cholecystitis to the med-surg unit. Which of the following actions are essential to the admission procedure? (Select all that apply.)
- A. Explain roles of other care delivery staff
- B. Begin discharge planning
- C. Provide info about advance directives
- D. Document the client's wishes about organ donation
- E. Introduce client to his roommate
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: Explaining roles of other care delivery staff helps manage client expectations and ensures effective communication among healthcare team members.
B: Beginning discharge planning early improves continuity of care and helps prevent delays in the discharge process.
C: Providing information about advance directives ensures the client's wishes are documented and respected in case of incapacitation.
E: Introducing the client to his roommate promotes social interaction and helps create a comfortable environment for the client.
Summary:
Choice D is incorrect as documenting organ donation wishes is not directly related to the admission process for acute cholecystitis.