Nurse talking with parents of 6 mo infant about gross motor...

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 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.

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,

A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP?

A. Feeding client who was admitted 24h ago with aspiration pneumonia
B. Reinforcing teaching w/ client who is learning to walk using quad cane
C. Reapplying a condom catheter for client who has urinary incontinence
D. Applying sterile dressing to pressure ulcer

Correct Answer: C

Rationale: The correct answer is C. The nurse can assign the task of reapplying a condom catheter for a client with urinary incontinence to an unlicensed assistive personnel (AP) because it is a routine, non-invasive procedure that does not require specialized nursing skills. The AP can be trained to perform this task safely under the nurse's supervision.

A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse.
B: Teaching a client to walk using a quad cane involves assessing the client's safety and gait, which should be done by a licensed nurse.
D: Applying a sterile dressing to a pressure ulcer requires knowledge of wound care principles and infection control, which should be done by a licensed nurse.

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.

RN is making assignments for client care to LPN at beginning of shift. Which of following assignments should LPN question?

A. Assisting a client who is 24h post-op to use incentive spirometer
B. Collecting clean-catch urine specimen from client who was admitted on previous shift
C. Providing nasopharyngeal suctioning for client with pneumonia
D. Replacing cartridge & tubing on PCA pump

Correct Answer: D

Rationale: The correct answer is D: Replacing cartridge & tubing on PCA pump. This is the assignment the LPN should question. The rationale is that LPNs are not typically trained to handle complex medical devices like PCA pumps, which deliver controlled doses of pain medication. LPNs should question this task as it involves intricate technical skills and potential risks if done incorrectly.

A: Assisting a client with an incentive spirometer is within an LPN's scope of practice and does not require specialized training.
B: Collecting a clean-catch urine specimen is a routine task that LPNs are typically trained to perform.
C: Providing nasopharyngeal suctioning for a client with pneumonia is a common nursing intervention that LPNs are qualified to carry out.

In summary, LPNs should question assignments that are outside their scope of practice or involve technical procedures beyond their training to ensure safe and effective care for the clients.