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A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?
- A. Loss of bone mass
- B. Loss of strength
- C. Loss of weight
- D. Loss of hope
Correct Answer: D
Rationale: The correct answer is D: Loss of hope. When a patient is immobile, they may experience feelings of hopelessness, leading to negative psychosocial impacts. The nurse must address this aspect in the care plan to promote the patient's mental well-being. Loss of bone mass (A), loss of strength (B), and loss of weight (C) are physical aspects related to immobility, not psychosocial. These factors are important but do not directly address the patient's emotional state. It is crucial for the nurse to focus on the psychosocial well-being of the patient to provide holistic care.
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Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.)
- A. Assembling puzzles
- B. Pulling wheeled toys
- C. Using musical toys
- D. Using finger paints
- E. Coloring with crayons
Correct Answer: A,C,E
Rationale: The correct activities for preschoolers are A, C, and E. A: Assembling puzzles promotes problem-solving and fine motor skills. C: Using musical toys enhances auditory skills and creativity. E: Coloring with crayons supports fine motor skills and creativity. B: Pulling wheeled toys may not be safe or developmentally appropriate. D: Using finger paints can be messy and may not be suitable for all children, especially those with sensory sensitivities.
A nurse is receiving a provider prescription by phone for morphine for a client who is reporting moderate to severe pain. Which of the following actions are appropriate?
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber's signature within 24 hours
- D. Decline verbal prescription because it is not an emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A,B,C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details of the prescription back to the provider ensures accuracy and reduces errors in transcription.
B: Having another nurse listen to the phone prescription provides a second verification to ensure accuracy and compliance with protocols.
C: Obtaining the prescriber's signature within 24 hours is necessary for legal documentation and accountability.
Summary:
Option D is incorrect because declining a verbal prescription in a non-emergency situation could delay necessary pain relief for the client. Option E is irrelevant to the immediate task of correctly processing the prescription.
Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. Confidence
- B. Perseverance
- C. Integrity
- D. Discipline
Correct Answer: D
Rationale: The correct answer is D: Discipline. The nurse demonstrated discipline by using the head-to-toe approach, ensuring a systematic and thorough assessment. This approach helps in identifying any abnormalities or potential issues before surgery. Confidence (A) is important but not specific to the method used. Perseverance (B) and integrity (C) are valuable traits but not directly related to the assessment approach. The nurse's systematic and methodical approach reflects discipline, making it the most appropriate choice.
Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field?
- A. Provider drops sterile instrument onto near side of sterile field
- B. Nurse moistens cotton ball with sterile NS & places it on sterile field
- C. Procedure is delayed 1h because provider receives emergency call
- D. Nurse turns to speak to someone who enters through door behind nurse
- E. Client's hand brushes against outer edge of sterile field
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D.
B: Moistening a cotton ball with sterile NS and placing it on the sterile field introduces moisture and potentially non-sterile material, contaminating the field.
C: Delaying the procedure for an hour increases the risk of airborne contaminants settling on the sterile field.
D: Turning to speak to someone who enters behind the nurse can lead to inadvertent contact with non-sterile areas, contaminating the field.
Incorrect choices:
A: While dropping a sterile instrument close to the field is not ideal, it may not necessarily contaminate the field unless it actually touches it.
E: Client's hand brushing against the outer edge of the field is a potential contamination point, but it does not directly contaminate the sterile field.
Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct recommendations to include are Varicella (B), Polio (C), and Seasonal influenza (E). Varicella vaccination prevents chickenpox, a common childhood illness. Polio vaccination is crucial to prevent the spread of polio, a highly contagious disease that can cause paralysis. Seasonal influenza vaccination is recommended to protect against the flu, which can be severe in young children. Haemophilus influenzae type b (A) is typically given in infancy, not preschool years. Hepatitis A (D) is recommended for older children and high-risk groups, not necessarily preschoolers.