Nokea
A nurse is delegating tasks to assistive personnel. Which of the following should the nurse consider when using one of the five rights of delegation?
- A. The assistive personnel's ability to complete the task without assistance
- B. The assistive personnel's level of experience and competency in performing the task
- C. The assistive personnel's rapport with clients
- D. The assistive personnel's availability at the time of the delegation
Correct Answer: B
Rationale: The correct answer is B: The assistive personnel's level of experience and competency in performing the task. When delegating tasks, the nurse must consider the individual's ability to safely and effectively perform the task. Choosing someone with the appropriate experience and competency minimizes the risk of errors or harm to the patient. Additionally, considering the person's level of experience ensures that they have the necessary skills to handle the task independently. Choices A, C, and D are incorrect as they do not directly address the crucial aspect of competency and experience required for safe delegation.
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The community health nurse is educating new nurses on the spread of infectious diseases. The nurse utilizes which of the following approaches to explain the factors that allow the reproduction and spread of infectious disease?
- A. Epidemiologic triangle
- B. Levels of prevention
- C. Natural history of disease
- D. Health Promotion
Correct Answer: A
Rationale: The correct answer is A: Epidemiologic triangle. This model explains infectious disease spread by considering the interactions between the host, agent, and environment. Host factors include susceptibility to the disease, agent factors refer to the infectious microorganism, and environmental factors influence transmission. This approach helps new nurses understand the complex interplay of factors leading to disease transmission. Choices B, C, and D are incorrect because they do not specifically address the factors involved in the reproduction and spread of infectious diseases. Level of prevention refers to actions taken to prevent disease, natural history of disease focuses on disease progression, and health promotion aims to improve overall health but does not directly explain disease spread.
A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
- A. Red tag
- B. Black tag
- C. Green tag
- D. Yellow tag
Correct Answer: A
Rationale: The correct answer is A: Red tag. The nurse assigns a red tag based on the assessment findings of a high respiratory rate, weak rapid pulse, and uncontrolled bleeding, indicating a critically injured patient requiring immediate intervention. Red tag signifies priority 1 according to NATO guidelines, indicating the need for immediate life-saving interventions. Other choices are incorrect because Black tag (B) is used for deceased or non-salvageable patients, Green tag (C) for minor injuries, and Yellow tag (D) for delayed or non-urgent care. In this scenario, the patient's critical condition necessitates the assignment of a red tag for prompt and urgent care.
The public health nurse is assigned to the population of clients in an inner-city community. The nurse identifies which of the following as a priority intervention?
- A. Develop a survey on teen pregnancies
- B. Hold a focus group to discuss immunizations
- C. Perform a windshield survey
- D. Interview the elderly at the senior's center
Correct Answer: C
Rationale: The correct answer is C: Perform a windshield survey. This is the priority intervention because it involves assessing the community's overall health needs and resources by physically observing the environment. It helps in identifying key health issues, resources, and potential areas for intervention. Developing a survey on teen pregnancies (A) may be important but not a priority without assessing the community first. Holding a focus group on immunizations (B) is valuable but may not address the broader health needs of the community. Interviewing the elderly at the senior's center (D) is specific and may not represent the entire community.
The nurse is caring for a client with multiple sclerosis. What action does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?
- A. Encourage the client to use ice therapy to alleviate muscle stiffness
- B. Administer interferon
- C. Administer corticosteroids
- D. Encourage the client to perform gentle stretching exercises daily
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to perform gentle stretching exercises daily. Stretching exercises help increase venous return by improving circulation, prevent stiffness by maintaining joint flexibility, and maintain muscle strength and endurance by promoting muscle health. Ice therapy (choice A) may temporarily alleviate stiffness but does not address venous return or muscle strength. Administering interferon (choice B) and corticosteroids (choice C) are medications used for managing symptoms but do not directly address the goals of increasing venous return or maintaining muscle strength.
A community health nurse is conducting an educational program on various environmental pollutants. The nurse should emphasize that clients who have which of the following disorders are especially vulnerable to ozone effects?
- A. Seasonal allergies
- B. Mitral valve disease
- C. Nasal polyps
- D. Asthma
Correct Answer: D
Rationale: The correct answer is D: Asthma. Clients with asthma are especially vulnerable to the effects of ozone due to their compromised respiratory system. Ozone can trigger asthma symptoms and exacerbate respiratory distress in individuals with asthma. Asthma is a chronic inflammatory condition of the airways, making it more susceptible to damage from environmental pollutants like ozone. Seasonal allergies (A), mitral valve disease (B), and nasal polyps (C) are not directly related to respiratory function and therefore not as vulnerable to ozone effects. In summary, asthma is the correct answer because of its direct impact on the respiratory system, making individuals with asthma more susceptible to the harmful effects of ozone.