Nokea
A nurse educator is conducting a parenting class for new parents. Which of the following statements made by a participant indicates a need for further clarification & instruction?
- A. I will begin swimming lessons as soon as my baby can close her mouth under water.'
- B. Once my baby can sit up, he should be safe in the bathtub.'
- C. I will test the temp of the water before placing my baby in the bath.'
- D. Once my infant starts to push up, I will remove the mobile from over the bed.'
Correct Answer: B
Rationale: The correct answer is B: "Once my baby can sit up, he should be safe in the bathtub." This statement indicates a need for further clarification because infants are not safe to be left unattended in the bathtub even if they can sit up. They are still at risk of drowning. It is essential for the caregiver to always supervise the baby closely during bath time to ensure their safety. Testing the water temperature (Choice C) and removing the mobile from over the bed (Choice D) are appropriate safety measures. Beginning swimming lessons when the baby can close her mouth under water (Choice A) may be premature but not necessarily dangerous.
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A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client & family teaching by the nurse should include which of the following? Select all.
- A. Apply petroleum jelly around the inside of the nares
- B. Remove the nasal cannula during mealtimes
- C. Check the position of the cannula often
- D. Report any nasal stuffiness, nausea, or fatigue
- E. Post 'no smoking' signs in a prominent location
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E.
C: Checking the position of the cannula often ensures proper oxygen delivery and prevents skin breakdown.
D: Reporting nasal stuffiness, nausea, or fatigue is crucial as they may indicate oxygen therapy-related complications.
E: Posting 'no smoking' signs is essential as oxygen is flammable and smoking near oxygen can lead to fires.
A: Applying petroleum jelly can interfere with oxygen delivery and increase the risk of skin breakdown.
B: Removing the nasal cannula during mealtimes can decrease oxygen levels, especially in clients requiring continuous therapy.
A nurse is teaching a young adult client about health promotion & illness prevention. Which of the following statements by the client indicates an understanding of the teaching?
- A. I already had my immunizations as a child, so I'm protected in that area.'
- B. It is important to schedule routine health care visits even if I'm feeling well.'
- C. If I'm having any discomfort, I'll just go to an urgent care center.'
- D. If I am feeling stressed, I will remind myself that this is something I should expect.'
Correct Answer: B
Rationale: The correct answer is B: It is important to schedule routine health care visits even if I'm feeling well. This statement indicates an understanding of health promotion and illness prevention as it emphasizes the significance of preventive care to maintain overall health. Regular check-ups can help detect potential issues early on.
Incorrect choices:
A: I already had my immunizations as a child, so I'm protected in that area.
- This statement shows a misunderstanding of the need for ongoing preventive measures beyond childhood immunizations.
C: If I'm having any discomfort, I'll just go to an urgent care center.
- This statement reflects a reactive approach rather than a proactive one towards health.
D: If I am feeling stressed, I will remind myself that this is something I should expect.
- This statement does not address health promotion or illness prevention strategies.
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
- A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use
- B. Nail polish should not be used near a client who is receiving oxygen
- C. A 'No smoking' sign should be placed on the front door
- D. Cotton bedding & clothing should be replaced with items made from wool
- E. A fire extinguisher should be readily available in the home
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Nail polish should not be used near a client who is receiving oxygen to prevent a fire hazard as it is flammable.
C: A 'No smoking' sign should be placed on the front door to remind visitors not to smoke near the oxygen source.
E: A fire extinguisher should be readily available in the home to handle any fire emergencies related to oxygen use.
Incorrect choices:
A: Family members who smoke must be at least 10 ft from the client when the oxygen is in use is not as crucial as preventing ignition sources like nail polish.
D: Replacing cotton bedding & clothing with wool is unnecessary for oxygen safety.
A client who had abdominal surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? Select all.
- A. Cover the area with saline-soaked sterile dressings
- B. Apply an abdominal binder snugly around the abdomen
- C. Use sterile gloves to apply gentle pressure to the exposed tissues
- D. Position the client supine with hips & knees bent
- E. Offer the client a warm beverage, such as herbal tea
Correct Answer: A, D
Rationale: Correct Answer: A, D
Rationale:
1. Covering the area with saline-soaked sterile dressings (Choice A) helps to protect the exposed tissues, prevent infection, and maintain a moist environment for healing.
2. Positioning the client supine with hips and knees bent (Choice D) can help reduce tension on the wound, alleviate pain, and minimize the risk of further tissue damage.
Summary:
- Applying an abdominal binder (Choice B) may increase pressure on the wound, exacerbating the situation.
- Using sterile gloves to apply pressure to exposed tissues (Choice C) can introduce contamination and should be avoided.
- Offering a warm beverage (Choice E) is irrelevant and does not address the urgent need to manage the wound.