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A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct Answer: B
Rationale: The correct answer is B: Changing the patient's position. This task can be delegated to nursing assistive personnel as it involves physically moving the patient, which does not require advanced nursing knowledge or assessment skills. Nursing assistive personnel are trained to safely reposition patients under the supervision of a nurse. Choices A, C, and D involve critical thinking, assessment, and decision-making skills that require a nurse's expertise, so they cannot be delegated.
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Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.)
- A. Building models
- B. Playing video games
- C. Reading books
- D. Using toy carpentry tools
- E. Shaping modeling clay
Correct Answer: A,B,C
Rationale: The correct activities for school-age children should be developmentally appropriate and engaging. Building models (A) promotes creativity and fine motor skills. Playing video games (B) can be stimulating and entertaining. Reading books (C) encourages literacy and imagination. Toy carpentry tools (D) may pose safety risks. Shaping modeling clay (E) is suitable but less interactive than the correct choices. In summary, A, B, and C are the best options for promoting active engagement and development in school-age children.
A nurse tells a client that she will call the surgeon about his request. The surgeon prescribes a full liquid diet. Which level of critical thinking did the nurse use?
- A. Basic
- B. Commitment
- C. Complex
- D. Integrity
Correct Answer: A
Rationale: The correct answer is A: Basic. The nurse's action of informing the surgeon about the client's request and following the prescribed full liquid diet shows a basic level of critical thinking. This decision involves understanding and following prescribed protocols without much analysis or interpretation. The other choices are incorrect because: B: Commitment would involve making a commitment to a course of action, C: Complex would involve analyzing and synthesizing information from various sources, and D: Integrity would involve adherence to ethical principles.
Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A) Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C) Turning pot handles toward the back of the stove prevents toddlers from accidentally pulling them down. D) Placing safety gates across stairways prevents toddlers from falling down stairs. B) Keeping toilet seats up increases the risk of toddlers falling in. E) Having balloons fully inflated poses a choking hazard. In summary, choices A, C, and D are important strategies for accident prevention, while choices B and E can actually increase risks for toddlers.
A nursing instructor is reviewing steps of the nursing process with students. Which of the following data are objective?
- A. Respiratory rate 22/min
- B. I can only walk 3 blocks before pain starts
- C. Pain level 3/10
- D. Skin pink warm
- E. Urine output 300mL/8hr
- F. Dressing clean dry intact
Correct Answer: A,D,E,F
Rationale: The correct answers are A, D, E, and F. Objective data are measurable and observable.
A: Respiratory rate 22/min is measurable.
D: Skin pink warm is observable.
E: Urine output 300mL/8hr is measurable.
F: Dressing clean dry intact is observable.
Choices B and C are subjective as they are based on the patient's perception and cannot be measured or observed directly. Choice G is incomplete.
Nurse is caring for client with SARS. Nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate rationale for reporting?
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A,B,C,E
Rationale: The correct answer is A, B, C, and E. Reporting communicable diseases like SARS is essential for planning and evaluating control and prevention strategies. It helps determine public health priorities by identifying areas of concern. Reporting ensures proper medical treatment for affected individuals and helps in monitoring for common-source outbreaks to prevent further spread. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases. Identifying endemic diseases may be a part of reporting, but it is not the primary reason.