Nokea
A nurse is preparing for the admission of a client with pulmonary tuberculosis. Which action reflects the use of evidence-based practice in the care of the client?
- A. Keeping the door to the client's room closed
- B. Fitting the client for an N95 or HEPA (high-efficiency particulate air) mask to be worn at all times
- C. Placing the client in a semiprivate room with a cohort client
- D. Using a surgical mask when entering the client's room
Correct Answer: A
Rationale: Evidence-based practice is an approach to client care that integrates the client's preferences, clinical expertise, and the best research evidence to deliver quality care. In the case of pulmonary tuberculosis, which is transmitted through the airborne route, keeping the door to the client's room closed is crucial to prevent the spread of infection. Placing the client in a semiprivate room with a cohort client is not recommended for airborne precautions; a private room is required to prevent transmission. Fitting the client for an N95 or HEPA mask is essential for the nurse's protection when entering the room, not for the client to wear at all times. Using a surgical mask when entering the client's room is not sufficient for airborne precautions; an N95 or HEPA mask is necessary.
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A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except:
- A. document the current functional status
- B. have the physician fax a report to the receiving facility
- C. copy appropriate parts of the medical record for transport to the receiving facility
- D. phone a report to the facility
Correct Answer: B
Rationale: To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.
How is the information documented on incident reports used?
- A. to analyze risk categories
- B. to ensure compliance with regulations
- C. to identify staff's educational needs
- D. all of the above
Correct Answer: D
Rationale: The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'
Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct Answer: A
Rationale: Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.
The LPN has been given assignments by the RN. Which assignment should the LPN question as being beyond the scope of the LPN?
- A. The LPN is assigned to care for a client with diabetes mellitus who needs instructions reinforced on how to self-administer insulin.
- B. The LPN is assigned to reinforce discharge teaching about dressing changes and medications to a 35-year-old man.
- C. The LPN is assigned to care for a 75-year-old woman, hospitalized for dehydration, who is being discharged home today with no medications.
- D. The LPN is assigned to care for a woman with newly diagnosed leukemia who will be receiving her initial dose of chemotherapy.
Correct Answer: D
Rationale: The LPN should be able to recognize when an assignment is beyond their scope of practice. Administering chemotherapy for leukemia is not within the scope of practice for the LPN, and this assignment should be questioned. Choices A, B, and C are within the scope of practice for an LPN. Reinforcing teaching on self-administration of insulin, assisting with discharge instructions on dressing changes, and caring for a client being discharged with no medications are all appropriate tasks for an LPN.
Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:
- A. a full-body assessment is not specific to nail and foot care.
- B. the essential lab work of the client is not related to nail and foot assessments.
- C. the nail beds and the tissue surrounding the nails.
- D. foot corns and calluses only neglect other important aspects of nail and foot care.
Correct Answer: C
Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.