Nokea
A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?
- A. Keep the client in their room with the door closed
- B. Contact a family member to come and sit with the client
- C. Place the client in a wheelchair with a lap tray
- D. Administer a sedative to the client
Correct Answer: B
Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.
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What is an episiotomy?
- A. A surgical incision of the perineum to prevent tearing during delivery.
- B. Releasing the red plug from the cervix just before crowning occurs.
- C. An incision in the abdomen with which the baby can be delivered through.
- D. The severance of the umbilical cord between mother and child.
Correct Answer: A
Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.
When reinforcing teaching and instructing the patient, which basic principle of teaching should you follow?
- A. Sequence the instruction from the least complex to the most complex.
- B. Assume that the patient knows little or nothing about the topic.
- C. Tell the patient to call their significant other so you can instruct them.
- D. Use medically oriented terms so the patient will be able to speak with the doctor.
Correct Answer: A
Rationale: The correct principle of teaching to follow when reinforcing teaching and instructing the patient is to sequence the instruction from the least complex to the most complex. This approach facilitates learning by building upon simpler concepts before moving to more advanced ones. Choice B is incorrect because assuming the patient knows little or nothing about the topic may not always be accurate and can be patronizing. Choice C is incorrect as it does not focus on the direct teaching approach to the patient. Choice D is incorrect as using medically oriented terms may confuse the patient rather than facilitate understanding.
Which of the following healthcare providers can legally have access to all, or part, of a patient's medical record because they have a 'need to know'? Select one that does not apply.
- A. Student nurses caring for a particular patient
- B. Registered nurses when they are not caring for a particular patient
- C. The Vice President for nursing who is investigating a patient fall
- D. Licensed practical nurses caring for a particular patient
Correct Answer: B
Rationale: Student nurses, licensed practical nurses, the Vice President for nursing investigating a fall, and quality assurance nurses have a 'need to know' basis to access patient records. Registered nurses who are not directly involved in the care of a patient do not have a legitimate reason or 'need to know' to access that patient's medical records, making choice B the correct answer. The Vice President for nursing investigating a specific incident and licensed practical nurses directly involved in a patient's care have legitimate reasons to access the medical records, ensuring continuity and quality of care.
You are working on a pediatric unit. Which toy or other diversional item or activity is most appropriate for your 18-month-old patient?
- A. Story books
- B. Beach balls
- C. An interactive play session with other children less than 2 years of age
- D. Pickup sticks
Correct Answer: B
Rationale: A beach ball is appropriate for an 18-month-old as it is safe and can help with motor skills development. Choice A, storybooks, may not be suitable for this age group due to limited attention span. Choice C involves interaction with other children which may not always be feasible in a healthcare setting. Choice D, pickup sticks, poses a choking hazard and is not suitable for toddlers.
A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?
- A. Measuring oxygen saturation for a client who has dyspnea
- B. Inserting a rectal suppository for a client who is vomiting
- C. Performing nasal hygiene for a client who has an NG tube
- D. Pouching a client's ostomy bag for a new colostomy
Correct Answer: D
Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.