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A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.
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A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation?
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E.
B: Right supervision/evaluation ensures proper oversight and assessment of tasks delegated.
C: Right direction/communication emphasizes clear instructions and effective communication.
E: Right circumstances require considering factors such as workload, staff competency, and patient condition.
A: Right client is not part of the five rights of delegation.
D: Right time is important but not specifically part of the five rights of delegation.
Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?
- A. Client evaluates his behavior after social interaction
- B. Client states he is learning to trust others
- C. Client wishes to find meaningful relationships
- D. Client expresses concerns about next generation
Correct Answer: D
Rationale: The correct answer is D: Client expresses concerns about the next generation. This behavior aligns with Erikson's task of generativity vs. stagnation in middle adulthood. This stage involves contributing to future generations through mentoring, guiding, and caring for others. Expressing concerns about the next generation demonstrates a sense of responsibility and investment in the well-being of future individuals.
A: Evaluating behavior after social interaction pertains more to self-reflection and self-awareness, not specifically related to generativity.
B: Learning to trust others is more aligned with Erikson's earlier stage of trust vs. mistrust in infancy.
C: Wishing to find meaningful relationships is associated with Erikson's intimacy vs. isolation stage in young adulthood, not middle adulthood.
A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct Answer: B
Rationale: The correct answer is B: Changing the patient's position. This task can be delegated to nursing assistive personnel as it involves physically moving the patient, which does not require advanced nursing knowledge or assessment skills. Nursing assistive personnel are trained to safely reposition patients under the supervision of a nurse. Choices A, C, and D involve critical thinking, assessment, and decision-making skills that require a nurse's expertise, so they cannot be delegated.
Nurse caring for 19-year-old client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?
- A. Measure the vital signs
- B. Encourage HIV screening
- C. Determine client's risk factors
- D. Instruct client to use condoms
Correct Answer: C
Rationale: The correct answer is C: Determine client's risk factors. This is the most appropriate intervention to assess the client's health promotion and disease prevention needs. By identifying the client's risk factors such as sexual behaviors, substance use, family history, and lifestyle choices, the nurse can tailor health education and intervention strategies to promote overall well-being.
A: Measure the vital signs - While important, vital signs do not directly assess health promotion and disease prevention needs in a sexually active young adult.
B: Encourage HIV screening - Important for sexual health but does not address a comprehensive assessment of health promotion and disease prevention.
D: Instruct client to use condoms - Important recommendation for safe sex practices but does not address the broader health promotion and disease prevention needs of the client.
The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
- A. Maintain a narrow base of support.
- B. Encourage the patient to dangle at the bedside.
- C. Encourage isometric exercises at the bedside.
- D. Suggest a high-calcium diet.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to dangle at the bedside. This is the first step in ambulating a patient who has been in bed for several days. Dangling helps prevent postural hypotension by allowing the patient's body to adjust gradually to an upright position. Maintaining a narrow base of support (A) is important during ambulation but comes after dangling. Isometric exercises (C) and suggesting a high-calcium diet (D) are not immediate actions needed for ambulation.