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A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
- A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use
- B. Nail polish should not be used near a client who is receiving oxygen
- C. A 'No smoking' sign should be placed on the front door
- D. Cotton bedding & clothing should be replaced with items made from wool
- E. A fire extinguisher should be readily available in the home
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Nail polish should not be used near a client who is receiving oxygen to prevent a fire hazard as it is flammable.
C: A 'No smoking' sign should be placed on the front door to remind visitors not to smoke near the oxygen source.
E: A fire extinguisher should be readily available in the home to handle any fire emergencies related to oxygen use.
Incorrect choices:
A: Family members who smoke must be at least 10 ft from the client when the oxygen is in use is not as crucial as preventing ignition sources like nail polish.
D: Replacing cotton bedding & clothing with wool is unnecessary for oxygen safety.
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A nurse is caring for a client who has had diarrhea for the past 4 days. When assessing the client, the nurse should expect which of the following findings? Select all.
- A. Bradycardia
- B. Hypotension
- C. Fever
- D. Poor skin turgor
- E. Peripheral edema
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. Diarrhea leads to fluid loss, causing hypotension (B) due to decreased blood volume, fever (C) as a result of dehydration and infection, and poor skin turgor (D) due to decreased tissue hydration. Bradycardia (A) is unlikely as the body compensates for dehydration with increased heart rate. Peripheral edema (E) is not expected as dehydration leads to fluid depletion, not retention.
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation?
- A. "Right client"
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. The 5 rights of delegation are essential for safe and effective delegation. Right supervision/evaluation ensures appropriate oversight, feedback, and accountability. Right direction/communication emphasizes clear instructions and open communication. Right circumstances consider factors like workload and resources. Right client (choice A) and right time (choice D) are not part of the 5 rights of delegation. In summary, choices A and D are incorrect because they do not align with the established principles of delegation, while choices B, C, and E are crucial components for successful delegation.
A nurse is caring for a client who reports severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client is experiencing noticeable symptoms such as severe sore throat, pain when swallowing, and swollen lymph nodes. This indicates that the infection has progressed to the point where the body is actively fighting off the pathogen, resulting in the manifestation of symptoms. The other choices are incorrect because: A: Prodromal stage is characterized by mild, nonspecific symptoms. B: Incubation stage is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence stage is the recovery period after the illness when symptoms start to improve.
A nurse in a provider's office is preparing to assess a young adult male client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? Select all.
- A. A concave thoracic spine posteriorly
- B. An exaggerated lumbar curvature
- C. A concave lumbar spine posteriorly
- D. An exaggerated thoracic curvature
- E. Muscles slightly larger on his dominant side
Correct Answer: C, E
Rationale: Correct Answer: C, E
Rationale:
C: A concave lumbar spine posteriorly is expected in a young adult male due to the normal lordotic curve in the lumbar region for weight-bearing support.
E: Muscles slightly larger on his dominant side is an expected finding as asymmetry in muscle size and strength is common due to dominant limb use.
Incorrect Choices:
A: A concave thoracic spine posteriorly is not a normal finding and may indicate poor posture or spinal deformity.
B: An exaggerated lumbar curvature is not expected in a young adult male and may suggest a potential spinal issue.
D: An exaggerated thoracic curvature is not typical in a young adult male and may indicate abnormal spinal curvature.
A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all.
- A. Stage III pressure ulcer
- B. Sutured surgical incision
- C. Casted bone fracture
- D. Laceration sealed with adhesive
- E. Open burn area
Correct Answer: A, E
Rationale: The correct answers are A and E because wounds healing by secondary intention involve tissue loss and heal from the bottom up with granulation tissue filling in the wound. A Stage III pressure ulcer and an open burn area are examples of wounds that heal by secondary intention due to tissue loss.
Choices B and D are incorrect because sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, where wound edges are approximated and heal with minimal scarring. Choice C, a casted bone fracture, is incorrect as fractures heal through a different process involving the formation of callus and subsequent bone remodeling, not by secondary intention healing.