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A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?
- A. Break needles on syringes before disposal
- B. Use two hands to recap a needle after administering a medication
- C. Dispose of used razors in wastebaskets
- D. Replace sharps containers when they are 3/4 full
Correct Answer: D
Rationale: The correct answer is D: Replace sharps containers when they are 3/4 full. This instruction is crucial in preventing puncture injuries as overfilling sharps containers can increase the risk of accidental needle sticks. By replacing the containers when they are 3/4 full, it ensures that there is enough space to safely dispose of needles and other sharp objects without risking spills or injuries.
Explanation of other choices:
A: Breaking needles on syringes before disposal is unsafe as it can increase the risk of needle stick injuries.
B: Using two hands to recap a needle is dangerous and not recommended as it can lead to accidental needle sticks.
C: Disposing of used razors in wastebaskets is improper as they should be disposed of in puncture-proof containers.
Summary: Option D is the correct choice as it emphasizes safe disposal practices to prevent puncture injuries, while the other options promote unsafe practices that can increase the risk of needle stick injuries.
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A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)?
- A. Heart failure
- B. Brainstem injury
- C. Recent weight loss
- D. Enlarged tonsils
Correct Answer: D
Rationale: The correct answer is D: Enlarged tonsils. Enlarged tonsils can physically obstruct the airway during sleep, leading to obstructive sleep apnea (OSA). This obstruction causes pauses in breathing during sleep, resulting in disrupted sleep patterns and decreased oxygen levels in the blood. Heart failure (A) is incorrect because it is not a direct cause of OSA. Brainstem injury (B) may disrupt the sleep-wake cycle but is not a common cause of OSA. Recent weight loss (C) can actually improve OSA symptoms by reducing the amount of tissue in the airway. Therefore, the most likely condition to cause OSA among the choices given is enlarged tonsils.
A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?
- A. Use hot water to rinse hand sanitizer off
- B. Dry hands with a reusable towel
- C. Rub hands together 20 seconds
- D. Rub hand sanitizer around rings on fingers
Correct Answer: D
Rationale: The correct answer is D: Rub hand sanitizer around rings on fingers. This is important because rings can harbor bacteria and viruses, and by rubbing hand sanitizer around them, the nurse ensures that all surfaces of the hands, including under the rings, are effectively sanitized. This action helps prevent the transmission of pathogens.
A: Using hot water to rinse hand sanitizer off is unnecessary and can actually be harmful as it can cause skin irritation.
B: Drying hands with a reusable towel is not recommended as it can harbor germs and compromise hand hygiene.
C: Rubbing hands together for 20 seconds is a good practice, but the specific action related to rings is more crucial.
E, F, G: No information provided.
A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Keep the head of the client’s bed elevated to 45
- B. Provide the client with a high-calorie diet
- C. Massage the client’s bony prominences
- D. Reposition the client every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Provide the client with a high-calorie diet. A high-calorie diet can help promote tissue healing and prevent pressure injuries by providing the necessary nutrients for skin integrity. Keeping the head of the bed elevated to 45 degrees (A) is important for preventing aspiration but not directly related to preventing pressure injuries. Massaging bony prominences (C) can actually increase the risk of pressure injuries by causing friction and shear forces. Repositioning the client every 4 hours (D) is essential but not directly related to the prevention of pressure injuries.
A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
- A. Orange juice
- B. Grapefruit juice
- C. Milk
- D. Carbonated beverage
Correct Answer: B
Rationale: The correct answer is B: Grapefruit juice. Grapefruit juice can interact with many medications by inhibiting the enzyme that metabolizes the drugs, leading to higher drug levels in the body and potentially causing adverse effects. Orange juice (A), milk (C), and carbonated beverages (D) do not have significant interactions with most medications. It is important for the nurse to advise older adult clients to avoid grapefruit juice to prevent medication interactions and ensure their safety.
A nurse is admitting a new client. Which of the following steps of the nursing process is the nurse performing when formulating goals to address an identified problem?
- A. Planning
- B. Implementation
- C. Assessment
- D. Evaluation
Correct Answer: A
Rationale: The correct answer is A: Planning. In the nursing process, planning involves formulating goals and developing a plan of action to address the identified problems from the assessment phase. During this step, the nurse sets specific, measurable, achievable, relevant, and time-bound (SMART) goals to guide the care provided. Planning ensures that interventions are tailored to the client's unique needs and helps achieve positive outcomes. The other choices are incorrect because: B: Implementation involves carrying out the plan, C: Assessment is the initial step of gathering data, and D: Evaluation is the final step to determine the effectiveness of the interventions.