Nokea
A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.
- A. tuberculosis
- B. influenza
- C. smallpox
- D. pertussis
Correct Answer: A,C
Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.
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A client on a 72-hour psychiatric hold experiences a panic attack while getting ready for the day. The nurse should provide the following interventions ranked by priority:
- A. stay with the client until the panic attack is over
- B. incorporate physical activity into the client's daily routine
- C. instruct the client to take slow, deep breaths
- D. reduce external stimuli in the immediate area
- E. work with the client to develop coping mechanisms
Correct Answer: A,D,C,E,B
Rationale: Priority order: Stay with the client (A) for safety, reduce stimuli (D) to calm the environment, instruct deep breathing (C) to manage symptoms, develop coping mechanisms (E) for future prevention, and incorporate physical activity (B) as a long-term strategy.
The nurse is precepting a student nurse who is helping to care for a client with a hip fracture. The client has Buck's traction applied. Which statement by the student nurse indicates a need for further explanation by the primary nurse?
- A. The weight on Buck's traction should be between 5 and 7 pounds.
- B. Buck's traction is a type of skeletal traction that helps in bone realignment.
- C. The weights should hang freely and be checked regularly for correct positioning.
- D. Diligent pin site care is crucial to prevent infection in clients with skeletal traction.
Correct Answer: B
Rationale: Buck’s traction is skin traction, not skeletal traction, which uses pins. The other statements are correct regarding weight, positioning, and pin care (though pin care applies to skeletal traction).
An RN delegates patient assignments to an LPN and nursing assistant. Later, the RN overhears a nursing assistant arguing with a patient regarding a late breakfast tray. The nursing assistant begins to raise his voice as the disagreement continues. The best action from the RN is
- A. call the nursing assistant out of the room and speak with him about the incident.
- B. apologize to the patient and assign another nursing assistant to that room.
- C. report the nursing assistant to the nursing manager for poor patient care.
- D. write an incident report and give a copy to the nursing assistant and nurse manager.
Correct Answer: A
Rationale: Addressing the nursing assistant privately de-escalates the situation, provides coaching, and maintains professionalism without immediate escalation.
Which of the following medication orders requires clarification before the nurse can administer the order?
- A. epinephrine (EpiPen) 0.25 mg IM STAT
- B. heparin 30 units/kg/hr IV infusion for 24 hours
- C. ampicillin (Omnipen) 500 mg PO bid
- D. lorazepam (Ativan) 1.0 mg PO prn
Correct Answer: B
Rationale: Heparin dosing (30 units/kg/hr) is unusually low for anticoagulation (typically 10-20 units/kg/hr). This requires clarification to ensure safety.
The nurse is caring for a client with full thickness burns to the lower half of the torso and lower extremities. During the emergent phase of injury, the primary nursing diagnosis would focus on:
- A. Ineffective airway clearance
- B. Impaired gas exchange
- C. Fluid volume deficit
- D. Pain
Correct Answer: C
Rationale: In the emergent phase of burns, fluid volume deficit is the priority due to massive fluid loss from damaged skin, risking hypovolemic shock.