Nokea
A nurse is preparing to assist with a lumbar puncture procedure for a patient. What action should the nurse take to maintain procedural asepsis?
- A. Wearing sterile gloves and a surgical mask during the procedure
- B. Cleansing the puncture site with povidone-iodine solution
- C. Using a sterile drape to cover the patient during the procedure
- D. Avoiding unnecessary movement or talking during the procedure
Correct Answer: A
Rationale: A nurse should wear sterile gloves and a surgical mask during a lumbar puncture procedure to maintain procedural asepsis. Sterile gloves help prevent contamination of the procedure site and reduce the risk of introducing microorganisms to the puncture site. Surgical masks help minimize the risk of respiratory secretions contaminating the sterile field, which is essential for maintaining asepsis during the procedure. Additionally, proper hand hygiene before and after the procedure is crucial in preventing the spread of infection.
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Choose how many times at least the nurses conducts physical assessment to school children.
- A. Thrice a year
- B. Every semester
- C. Every quarter
- D. Once a year
Correct Answer: A
Rationale: It is recommended for nurses to conduct physical assessments on school children at least three times a year, or thrice a year. This frequency allows nurses to monitor the children's growth and development, assess any changes in their health status, and provide early intervention if needed. Regular physical assessments help ensure that any health issues are identified promptly and addressed appropriately, promoting the overall well-being and academic performance of the students.
A postpartum client reports feeling emotional and tearful despite no apparent physical discomfort. What nursing intervention should be prioritized to address the client's emotional well-being?
- A. Providing opportunities for rest and sleep
- B. Educating the client about the "baby blues" phenomenon
- C. Encouraging the client to engage in self-care activities
- D. Referring the client to a mental health professional
Correct Answer: B
Rationale: Educating the client about the "baby blues" phenomenon should be prioritized as it is a common occurrence that happens to many women after giving birth. The "baby blues" refer to feelings of sadness, irritability, and tearfulness that many new mothers experience due to hormonal changes and the stress of adjusting to motherhood. By understanding that these feelings are a normal part of the postpartum period and that they usually resolve on their own within a few weeks, the client may feel reassured and supported. Providing information and support can help the client cope with these emotions and reduce any anxiety or distress they may be feeling. If the client's emotional state does not improve or becomes more severe, further intervention such as referring to a mental health professional may be necessary. But initially, education and reassurance about the "baby blues" can be an effective nursing intervention to address the client's emotional well-being.
The day of discharge came and Marlene 's face becomes all the more sad. When asked why, she answered she has no money to pay the bill. The BEST way of communicating her piece of advice is stating which of the following?
- A. You can go to the cashier for to find out what she can advise you
- B. The government has agencies for those who need financial assistance. I will give you the list.
- C. You can always pay in staggered amounts to be given every 15 days
- D. Ask help from generous relatives so you can have additional for down payment.
Correct Answer: B
Rationale: In this situation, the best way to communicate Marlene's piece of advice would be to inform her about government agencies that provide financial assistance. This option provides a long-term solution for her financial difficulties rather than short-term fixes like asking relatives for help or paying in staggered amounts. By giving her information about available resources, you are empowering her to seek sustainable help for her financial situation. This approach focuses on addressing the root cause of her inability to pay the bill rather than temporary solutions.
A patient post-thyroidectomy develops signs of hypocalcemia, including tingling around the mouth and muscle cramps. Which action should the nurse take first?
- A. Administer oral calcium supplements
- B. Notify the healthcare provider
- C. Assess the patient's calcium level
- D. Encourage increased intake of dairy products
Correct Answer: C
Rationale: The first action the nurse should take when a patient post-thyroidectomy develops signs of hypocalcemia is to assess the patient's calcium level. By assessing the patient's calcium level through laboratory testing, the nurse can confirm the presence of hypocalcemia and determine the severity of the condition. This information will guide further interventions, such as administering calcium supplements or notifying the healthcare provider for additional management. It is important to confirm the diagnosis before proceeding with treatment to ensure appropriate and safe care for the patient.
In writing the IR, which of the following is not included?
- A. Who was / were involved?
- B. What daily medications are given to the patient
- C. What happened?
- D. Who witnessed the incident?
Correct Answer: B
Rationale: The IR (Incident Report) typically focuses on the details surrounding an incident or event, such as what happened, who was/were involved, and who witnessed the incident. Information about daily medications given to the patient is not usually included in an incident report, unless it directly relates to the incident itself (e.g., medication error). The primary focus of an incident report is to document the incident in a clear and factual manner for record-keeping and analysis purposes.