Nokea
Nurse is preparing discharge summary for client whose had knee surgery & is going home. Which following info about client should nurse include in it?
- 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
- F. Follow-up care
- G. medication
Correct Answer: B,C,E
Rationale: The correct answer includes where to go for follow-up care, instructions for diet/meds, and contact info for home healthcare agency. Follow-up care ensures continuity of care post-surgery. Instructions for diet/meds are crucial for recovery. Contact info for home healthcare agency facilitates additional support at home. Advance directives status is important but not directly related to post-surgery care. Most recent vital sign data is essential for monitoring during hospitalization, not for discharge summary. Just mentioning follow-up care or medication without specific details is not as comprehensive as providing detailed instructions and contact information.
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Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information to identify the location or nature of the threat. By actively listening, the security officer can gather valuable details without alerting the caller. Choice A is incorrect because abruptly ending the call may prevent gathering important information. Choice B is incorrect as overhead paging may cause panic. Choice C is incorrect as asking questions can elicit useful details.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face
- D. neck
- E. chest
Correct Answer: C
Rationale: The correct answer is C: Client with partial & full-thickness burns to face. This client is the highest priority due to airway compromise risk from facial burns. Airway is a top priority in mass casualty events to prevent respiratory distress or failure. Crush injuries (A) may be severe but not immediately life-threatening. Laceration (B) to head can be managed with proper wound care. Clients with neck (D) or chest (E) injuries may have potential serious complications, but airway takes precedence in this scenario.
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when a new nurse states that a client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke leads to severe dehydration and vasodilation, causing a drop in blood pressure (hypotension). Bradycardia (B), clammy skin (C), and bradypnea (D) are not characteristic of heat stroke. Bradycardia is a slow heart rate, while heat stroke typically causes tachycardia. Clammy skin is more indicative of shock or hypoglycemia, not heat stroke. Bradypnea is slow breathing, but heat stroke usually leads to rapid, shallow breathing. Therefore, hypotension is the most appropriate choice as it aligns with the physiological response to heat stroke.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion? (Select all that apply.)
- A. Rotavirus
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. Varicella (B) vaccine is recommended for adolescents who haven't been vaccinated before. HPV (D) vaccine is crucial for preventing certain types of cancers. Seasonal influenza (E) vaccine helps protect against the flu, which can be severe. Rotavirus (A) vaccine is typically given to infants, not adolescents. Herpes zoster (C) vaccine is for adults over 50. No information is given for choices F and G.