Nokea
A healthcare professional is preparing information for a change-of-shift report. Which of the following information should the healthcare professional include in the report?
- A. Input and output measurements for the shift
- B. Blood pressure readings from the previous day
- C. Bone scan scheduled for today
- D. Medication regimen from the medication administration record
Correct Answer: D
Rationale: During a change-of-shift report, healthcare professionals should include the medication regimen from the medication administration record. This information ensures continuity of care and helps incoming staff understand the patient's medication needs and schedule. While input and output measurements, blood pressure readings, and scheduled procedures like a bone scan are important aspects of patient care, they may not be immediately relevant for the incoming shift. Focusing on medication details helps prevent errors and ensures the patient receives the correct medications at the right times.
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A client is contemplating retirement and expresses uncertainty about wanting to retire. Which of the following responses should the nurse make?
- A. Let's talk about how the change in your job status will affect you.
- B. Have you considered the financial implications of retirement?
- C. What are your thoughts on retirement and how it may impact your life?
- D. Would you like to discuss potential activities you could engage in during retirement?
Correct Answer: A
Rationale: Choosing option A, 'Let's talk about how the change in your job status will affect you,' is the most appropriate response in this scenario. By discussing how retirement might affect the client, the nurse can address the client's concerns and emotions about the impending change. Option B, 'Have you considered the financial implications of retirement?' is not the best response as it focuses solely on financial aspects and does not address the client's emotional readiness for retirement. Option C, 'What are your thoughts on retirement and how it may impact your life?' is more open-ended and may not address the immediate concerns of the client expressing uncertainty. Option D, 'Would you like to discuss potential activities you could engage in during retirement?' assumes the client is certain about retiring and focuses on activities rather than addressing the client's feelings of uncertainty.
A healthcare professional is preparing to insert an NG tube for a client admitted with bowel obstruction. Which of the following should the healthcare professional do first?
- A. Explain the procedure to the client
- B. Measure the length of the NG tube
- C. Lubricate the NG tube
- D. Place the client in a high Fowler's position
Correct Answer: A
Rationale: Explaining the procedure to the client is the initial and most important step that the healthcare professional should take before inserting an NG tube. By explaining the procedure, the healthcare professional ensures the client's understanding, obtains informed consent, and fosters cooperation. Measuring the length of the NG tube, lubricating the tube, and positioning the client in a high Fowler's position are essential steps in the NG tube insertion process but should come after the client has been informed and consented to the procedure.
When responding to a call light and finding a client on the bathroom floor, what should the nurse do FIRST?
- A. Check the client for injuries
- B. Call for additional help
- C. Move the client to a sitting position
- D. Assist the client back to bed
Correct Answer: A
Rationale: Checking the client for injuries is the priority when finding them on the bathroom floor. This action ensures the client's safety as it allows for immediate assessment of any potential harm. Calling for help may be necessary, but assessing for injuries takes precedence to address any immediate threats to the client's well-being. Moving the client to a sitting position or assisting them back to bed should only be done after ensuring there are no serious injuries requiring prompt medical attention. Therefore, the correct first action is to check the client for injuries.
The nurse is providing care for a client with a wound infection. Which type of precautions should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: C
Rationale: Contact precautions are necessary when caring for a client with a wound infection to prevent the spread of infection. Contact precautions involve practices such as wearing gloves and gowns, and ensuring proper hand hygiene. Airborne precautions are for diseases transmitted by small droplet nuclei that can remain suspended in the air, like tuberculosis. Droplet precautions are for diseases transmitted through respiratory droplets larger than 5 microns, such as influenza. Standard precautions are used for all clients to prevent the spread of infection and include practices like hand hygiene, use of personal protective equipment, and safe injection practices. In this case, since the client has a wound infection, the nurse should focus on implementing contact precautions to reduce the risk of spreading the infection to themselves or others.
The caregiver is teaching parents about the diet for a 4-month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. Formula or breast milk
- B. Broth and tea
- C. Rice cereal and apple juice
- D. Gelatin and ginger ale
Correct Answer: A
Rationale: The correct answer is A: Formula or breast milk. In infants with gastroenteritis and mild dehydration, it is essential to continue feeding them with formula or breast milk along with oral rehydration fluids to provide adequate nutrition and maintain hydration. Option B, broth and tea, may not provide the necessary nutrients and electrolytes needed for the infant's recovery. Option C, rice cereal and apple juice, can be harsh on the digestive system and may exacerbate diarrhea. Option D, gelatin and ginger ale, do not provide the necessary nutrients and can worsen the condition due to the high sugar content in ginger ale.