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A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all.
- A. Slower light touch sensation
- B. Some vision & hearing decline
- C. Slower fine finger movement
- D. Some short-term memory decline
- E. Slower superficial pain sensation
Correct Answer: B, C, D
Rationale: The correct answer is B, C, D. Vision and hearing decline, slower fine finger movement, and some short-term memory decline are all changes associated with aging. Vision and hearing tend to decline due to changes in the eyes and ears. Fine finger movement slows down due to changes in muscle strength and coordination. Short-term memory may decline as a result of changes in the brain's ability to process information. Slower light touch sensation and slower superficial pain sensation are not typically associated with normal aging.
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A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all.
- A. I will observe for med side effects.
- B. I will monitor for therapeutic effects.
- C. I will prescribe the appropriate dose.
- D. I will change the dose if adverse effects occur.
- E. I will refuse to give a med if I believe it is unsafe.
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A nurse's responsibility in implementing medication therapy includes observing for side effects (A), monitoring for therapeutic effects (B), and refusing to give a medication if they believe it is unsafe (E).
A - Observing for side effects is crucial in ensuring patient safety and prompt intervention if adverse reactions occur.
B - Monitoring for therapeutic effects helps assess the effectiveness of the medication in achieving the desired outcomes for the patient's condition.
E - Refusing to give a medication if the nurse believes it is unsafe demonstrates advocacy for the patient's well-being and adherence to the principles of safe medication administration.
Choices C and D are incorrect because nurses should not prescribe or change medication doses without proper authorization from a prescribing healthcare provider. It is beyond the scope of a nurse's role.
In summary, the correct answers focus on patient safety, monitoring effectiveness, and advocating for the patient's best interest, while the incorrect choices involve actions outside the nurse's scope
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.
A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should the nurse include when explaining the procedure to the client?
- A. Eating more protein is optimal prior to testing
- B. One stool specimen is sufficient for testing
- C. A red color change indicates a positive test
- D. The specimen cannot be contaminated
Correct Answer: D
Rationale: The correct answer is D because a contaminated specimen can lead to false results. The client should be instructed to avoid contaminating the specimen with urine, water, or toilet bowl cleaners. Choice A is incorrect because protein intake does not affect the test. Choice B is incorrect as multiple stool specimens are usually required. Choice C is incorrect as a blue color change indicates a positive test, not red.
A nurse is reviewing the CDC's immunization recommendations with a young adult client. Which of the following recommendations should the nurse include in this discussion? Select all.
- A. Human papillomavirus
- B. Measles, mumps, rubella
- C. Varicella
- D. Haemophilus influenzae type b
- E. Polio
Correct Answer: A, B, C
Rationale: The correct answer includes Human papillomavirus (HPV), Measles, mumps, rubella (MMR), and Varicella vaccines. These vaccines are recommended by the CDC for young adults to prevent serious diseases. HPV vaccine helps prevent certain types of cancers, MMR protects against highly contagious viral infections, and Varicella prevents chickenpox. The incorrect choices, Haemophilus influenzae type b (Hib) and Polio, are typically given during infancy and are not part of routine vaccinations for young adults. In summary, the correct recommendations focus on preventing common infections in this age group, while the incorrect choices are either not relevant or administered at a different life stage.
A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique?
- A. I will straighten my ear canal by pulling my ear down & back.
- B. I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops.
- C. I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.
- D. After the drops are in, I will place a cotton ball all the way into my ear canal.
Correct Answer: B
Rationale: The correct answer is B: "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops." This statement indicates understanding of the proper technique because applying pressure to the tragus helps the ear drops to reach the ear canal. The tragus is a small cartilaginous projection in front of the ear canal that, when pressed, helps to facilitate the passage of the drops into the ear. This action ensures proper distribution of the medication for effective treatment.
Other choices are incorrect:
A: Pulling the ear down and back is a technique used for administering ear drops in children, not adults.
C: Inserting the nozzle snug into the ear can cause injury to the ear canal and eardrum.
D: Placing a cotton ball all the way into the ear canal can prevent the drops from reaching the ear canal and may cause blockage.