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A nurse delegating ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. Client ambulates with slippers over antiembolic stockings
- C. Client uses front-wheeled walker when ambulating
- D. Client had pain medication 30 min ago
- E. Client is allergic to codeine
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure proper footwear and prevent falls. Sharing that the client uses a front-wheeled walker when ambulating (C) is vital for safety and stability. Informing the AP that the client had pain medication 30 minutes ago (D) is crucial to prevent overexertion and ensure appropriate monitoring for side effects. Choice A is incorrect because the roommate's independence is not relevant to the client's ambulation. Choice E is also incorrect as the client's allergy to codeine is not directly related to ambulation delegation.
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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 preparing instructional session about managing stress incontinence for older adult. Which actions should nurse take first when meeting with client?
- A. Encourage client to participate actively in learning
- B. Select instructional materials appropriate for older adult
- C. Identify goals nurse & client can agree are reasonable
- D. Determine what client knows about stress incontinence
Correct Answer: D
Rationale: The correct answer is D: Determine what client knows about stress incontinence. This is the first step because it helps the nurse assess the client's baseline knowledge, tailor the information to their level of understanding, and avoid providing redundant information. Understanding the client's knowledge also helps to establish a starting point for education and to address any misconceptions. This approach promotes client-centered care and enhances the effectiveness of the educational session.
Choice A (Encourage client to participate actively in learning) is important but should come after assessing the client's knowledge. Choice B (Select instructional materials appropriate for older adult) is essential but should be based on the client's knowledge level. Choice C (Identify goals nurse & client can agree are reasonable) is important but should come after assessing the client's knowledge to set appropriate goals.
Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities? (Select all that apply.)
- A. Develop acceptance of diminished strength & increased dependence on others
- B. Feel frustrated that time is too short for trying to start another life
- C. Welcome opportunities to be creative & productive
- D. Commit to finding friendship & companionship
- E. Become involved in community issues & activities
Correct Answer: C,E
Rationale: The correct choices, C and E, align with Erikson's theory of psychosocial development for middle adulthood. Choice C, "Welcome opportunities to be creative & productive," reflects Erikson's stage of generativity versus stagnation, where individuals in middle adulthood seek to contribute to society and leave a legacy. Choice E, "Become involved in community issues & activities," relates to the desire for social involvement and making a positive impact on the community. Choices A, B, and D are incorrect because they do not align with the typical capabilities of middle adults according to Erikson's theory. Choice A contradicts the idea of middle adults striving for independence and self-reliance, while choice B reflects feelings of regret or despair, which are more characteristic of Erikson's later stages. Choice D, while important, does not capture the full scope of middle adulthood psychosocial development as outlined by Erikson.
Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline?
- A. Establish consistent boundaries
- B. Place him in room with door closed
- C. Have him learn by trial & error
- D. Use favorite snacks as rewards
Correct Answer: A
Rationale: The correct answer is A: Establish consistent boundaries. This is important because toddlers thrive on routine and predictability. Consistent boundaries help them understand what is expected of them and provide a sense of security. Choice B is inappropriate as isolating a child can lead to feelings of abandonment. Choice C is ineffective as toddlers need guidance and supervision to learn appropriate behavior. Choice D may lead to unhealthy eating habits and does not address the underlying behavior.
A nursing instructor is reviewing actions nurses can initiate without a provider's prescription. Which of the following are nurse-initiated?
- A. Give morphine 1-2 mg IV every 1h as needed
- B. Insert NG tube to relieve gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C,D,E
Rationale: The correct answers are C, D, and E. C: Nurses can educate clients on progressive muscle relaxation techniques without a prescription to promote relaxation. D: Providing daily baths is part of basic hygiene care and can be initiated by nurses without a prescription. E: Repositioning clients every 2 hours to prevent pressure ulcers is within the scope of nursing practice. A: Administering morphine requires a prescription due to the potential for adverse effects. B: Inserting an NG tube involves a medical procedure and should be prescribed by a provider.