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A nurse is planning discharge for a client who has rheumatoid arthritis. Which of the following statements by the client should the nurse identify as an indication that a referral to an occupational therapist is necessary?
- A. I'm having difficulty climbing the stairs at my house.
- B. I am tired of having pain in my joints all the time.
- C. I will need assistance with bathing.
- D. I need some help planning my meals to maintain my weight.
Correct Answer: C
Rationale: Difficulty with bathing, an activity of daily living, indicates a need for occupational therapy to address functional limitations.
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A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
- A. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.
- B. I will have a client who is on airborne precautions wear a mask when out of her room.
- C. I will wear an N95 respirator mask when caring for a client who is on droplet precautions.
- D. I will place a client who has compromised immunity in a negative-pressure airflow room.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates understanding of airborne precautions. Airborne precautions require clients to wear a mask when leaving their room to prevent the spread of infectious agents through the air. This statement aligns with the principle of protecting others from exposure.
Explanation for other choices:
A - Incorrect: Visitors, not clients, should wear masks on contact precautions to prevent the spread of infection to the client.
C - Incorrect: N95 respirator masks are used for airborne precautions, not droplet precautions.
D - Incorrect: Negative-pressure airflow rooms are used for clients on airborne precautions, not those with compromised immunity.
A nurse is caring for a client who has early-stage Alzheimer's disease. In which of the following actions is the nurse acting as a client advocate?
- A. Requesting a referral for the client to attend reminiscent therapy sessions
- B. Reorienting the client several times throughout the day
- C. Providing assistance for the client when ambulating down the hall
- D. Performing an updated cognitive assessment on the client
Correct Answer: A
Rationale: Requesting reminiscent therapy promotes the client's cognitive function and dignity, aligning with advocacy by prioritizing their best interests.
A charge nurse is receiving change-of-shift report. Which of the following situations should the charge nurse address first?
- A. The emergency department nurse is waiting to give report on a new admission.
- B. Two staff members have called to say they will be absent.
- C. A nurse on the previous shift wrote an incident report about a medication error.
- D. Transport assistance is unavailable to take a client to occupational therapy.
Correct Answer: A
Rationale: The correct answer is A because the charge nurse should address urgent situations first. The emergency department nurse waiting to give report on a new admission indicates a critical patient needing immediate attention. Addressing this first ensures timely and appropriate care for the patient. Choices B and D, staff absences and transport assistance availability, can be managed after addressing the urgent patient situation. Choice C, the incident report about a medication error, is important but not as time-sensitive as the new admission report. Therefore, the charge nurse should prioritize addressing the emergency department nurse's report first.
A nurse on a surgical unit is preparing to transfer a client to a rehabilitation facility. Which of the following information should the nurse include in the change-of-shift report?
- A. The client's preferred time for bathing
- B. The belief that the client has a difficult relationship with his son
- C. The time the client received his last dose of pain medication
- D. The steps to follow when providing wound care
Correct Answer: C
Rationale: The correct answer is C: The time the client received his last dose of pain medication. This information is crucial for ensuring continuity of care and preventing medication errors. It helps the rehabilitation facility staff know when the next dose is due and if any additional pain relief is needed.
A: The client's preferred time for bathing is important for comfort but not as critical as pain medication timing in a transfer report.
B: The belief about the client's relationship with his son is not relevant to the client's immediate care needs during transfer.
D: The steps for wound care are important but should be included in a separate document or care plan, not necessarily in a brief change-of-shift report.
A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?
- A. The nurse puts on a face mask.
- B. The nurse turns her back to the sterile field.
- C. The nurse holds her hands above her waist.
- D. The nurse applies goggles.
Correct Answer: C
Rationale: Holding hands above the waist maintains sterility, as areas below the waist are considered non-sterile.