A nurse is reviewing safety precautions with a group of youn...

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all.

A. Install bath rails & grab bars in bathrooms
B. Wear a helmet while skiing
C. Install a carbon monoxide detector
D. Secure firearms in a safe location
E. Remove throw rugs from the home

Correct Answer: B, C, D

Rationale: The correct recommendations for young adults are B, C, and D. Young adults are more likely to engage in activities like skiing that pose a risk of head injuries, hence wearing a helmet (B) is crucial. Carbon monoxide poisoning can occur from faulty heating systems or appliances, making it important to install a detector (C). Additionally, young adults may be more likely to own firearms, so securing them in a safe location (D) is essential to prevent accidents. Installing bath rails (A) and removing throw rugs (E) are more relevant to older adults to prevent falls.

A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?

A. Don't measure the client's temperature rectally.'
B. Count the client's radial pulse for 30 seconds & multiply by 2.'
C. Don't let the client know you are counting her respirations.'
D. Let the client rest for 5 minutes before you measure her BP.'

Correct Answer: A

Rationale: Correct Answer: A: Don't measure the client's temperature rectally.

Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.

Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.

A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer back to the unit from the PACU following thoracic surgery. To which staff member should the nurse assign this client?

A. Charge nurse
B. RN
C. LPN
D. AP

Correct Answer: B

Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from the PACU following thoracic surgery due to their advanced training and skill set. RNs are qualified to assess, monitor, and manage complex post-operative care needs, including respiratory status, pain management, and hemodynamic stability. Charge nurses may have administrative duties and may not be available to provide direct patient care. LPNs have a more limited scope of practice and may not have the necessary skills to care for a post-thoracic surgery patient. Advanced practice nurses (AP) typically have specialized roles and responsibilities that may not align with providing direct care in this situation.

A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?

A. Social worker
B. Certified nursing assistant
C. Registered dietitian
D. Occupational therapist

Correct Answer: D

Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.

A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.

A. Fever
B. Malaise
C. Edema
D. Pain or tenderness
E. Increase in pulse & respiratory rate

Correct Answer: A, B, E

Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.

A nurse is assessing a client who is 5 days postop following abdominal surgery. The surgeon suspects an incisional wound infection and has prescribed antibiotic therapy for the nurse to initiate after collecting wound & blood specimens for culture & sensitivity. Which of the following assessment findings should the nurse expect? Select all.

A. Increase in incisional pain
B. Fever & chills
C. Reddened wound edges
D. Increase in serosanguineous drainage
E. Decrease in thirst

Correct Answer: A, B, C

Rationale: The correct assessment findings the nurse should expect in a client suspected of having an incisional wound infection include: A) Increase in incisional pain: Infection can cause localized pain. B) Fever & chills: Systemic signs of infection. C) Reddened wound edges: Classic sign of wound infection. Incorrect choices: D) Increase in serosanguineous drainage: This is more indicative of normal wound healing. E) Decrease in thirst: Unrelated to wound infection. Overall, pain, fever, and redness are key signs of infection that the nurse should look out for.