Nokea
Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
- A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
- B. If the client is dizzy on standing, ask him to take some deep breaths.
- C. Assist the client to the bathroom at least twice on this shift.
- D. After you assist him to the chair, let me know how he feels.
Correct Answer: A
Rationale: Give clear information to the UAP about what is expected for client safety. This instruction ensures the client is assessed for orthostatic hypotension before ambulating, reducing the risk of falls.
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When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
- A. Provide a verbal explanation just prior to the surgery
- B. Provide the child with a booklet to read about the surgery
- C. Introduce the child to another child who had heart surgery 3 days ago
- D. Explain the surgery using a model of the heart
Correct Answer: D
Rationale: Explain the surgery using a model of the heart. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using a model to explain the surgery meets the child’s developmental needs for concrete and visual learning.
Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
How is the information documented on incident reports used?
- A. to analyze risk categories
- B. to make sure procedures are in compliance with regulations
- C. to identify the educational needs of the staff
- D. all of the above
Correct Answer: D
Rationale: Risk management utilizes information from incident reports to perform all of the tasks identified.
A client being treated for hypertension returns to the community clinic for follow up. The client says, 'I know these pills are important, but I just can't take these water pills anymore. I drive a truck for a living, and I can't be stopping every 20 minutes to go to the bathroom.' Which of these is the best nursing diagnosis?
- A. Noncompliance related to medication side effects
- B. Knowledge deficit related to misunderstanding of disease state
- C. Defensive coping related to chronic illness
- D. Altered health maintenance related to occupation
Correct Answer: A
Rationale: Noncompliance related to medication side effects. The client kept his appointment, and stated he knew the pills were important. He is unable to comply with the regimen due to side effects, not because of a lack of knowledge about the disease process.
The nurse is demonstrating the use of a fire extinguisher during a fire drill. Place the steps for using a fire extinguisher in the correct order.
- A. Squeeze the handle
- B. Sweep from side to side
- C. Pull the pin
- D. Aim at the base of the fire
Correct Answer: C,D,A,B
Rationale: The PASS technique is: Pull the pin (C), Aim at the base (D), Squeeze the handle (A), Sweep side to side (B).