Nokea
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which should be assigned to room closest to nursing station?
- A. 43 yo client post-op following laparoscopic cholecystectomy
- B. 61 yo client being admitted for telemetry to rule out MI
- C. 50 yo client post-op following open reduction internal fixation of ankle
- D. 79 yo client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79 yo client post-op following below-the-knee amputation should be assigned to a room closest to the nursing station for fall prevention. This client may have mobility challenges, increased risk of falls due to recent surgery, and may require closer monitoring and immediate assistance if needed. Placing the client near the nursing station allows for quick response to any fall risk or postoperative complications.
A: The 43 yo client post-op following laparoscopic cholecystectomy is not at high risk for falls compared to the amputee.
B: The 61 yo client being admitted for telemetry to rule out MI does not necessarily have a higher fall risk than the amputee.
C: The 50 yo client post-op following open reduction internal fixation of ankle may have mobility limitations but is not as high risk for falls as the amputee.
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Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. confidence
- B. perseverance
- C. integrity
- D. discipline
Correct Answer: D
Rationale: The correct answer is D: discipline. The nurse demonstrated discipline by following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.
Nurse observes smoke coming from under door of staff lounge. Which is priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The priority action for the nurse in this scenario is to evacuate the clients (Choice C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (Choice B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (Choice A) may put the nurse at risk and delay client evacuation. Closing doors (Choice D) may contain the fire but does not address the immediate need of client safety.
Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
1. Client scheduled for TURP (prostate resection): This client can be safely discharged as the procedure is elective and not urgent.
2. Client who is 24h post-op after mastectomy: This client is stable post-operation and can be discharged with appropriate follow-up care.
Summary of other choices:
A: Client who's dehydrated & receiving IV fluid/electrolytes - This client needs continued treatment and monitoring.
B: Client with NG tube to treat small bowel obstruction - This client requires ongoing treatment and observation.
E: Client scheduled for appendectomy - This client needs urgent surgical intervention and cannot be safely discharged.
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. "I already had my immunizations as a child
- B. so I'm protected in that area."
- C. It's important to schedule routine healthcare visits even if I'm feeling well.
- D. If I'm having any discomfort, I'll just go to an urgent care center.
- E. If I'm feeling stressed, I will remind myself that this is something I should expect.
Correct Answer: B
Rationale: The correct answer is B because the statement demonstrates an understanding of the importance of immunizations in preventing diseases. By acknowledging that immunizations from childhood offer protection, the client shows awareness of the role of vaccines in health promotion. Choice A only mentions past immunizations but does not indicate understanding of their ongoing importance. Choices C and D do not directly address health promotion or illness prevention. Choice E focuses on stress management rather than health maintenance.
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion?
- A. "rotavirus"
- B. varicella
- C. herpes zoster
- D. HPV
- E. seasonal influenza
Correct Answer: B, D, E
Rationale: The correct answers are B (varicella), D (HPV), and E (seasonal influenza) because these are recommended immunizations for adolescents by the CDC. Varicella vaccine protects against chickenpox, HPV vaccine prevents certain types of cancers, and seasonal influenza vaccine helps prevent the flu. Rotavirus (A) is typically given to infants, not adolescents. Herpes zoster (C) is recommended for older adults, not adolescents.