Nokea
During evaluation, nurse must gather info about the client to...
- A. identify whether client outcomes have been met
- B. organize resources to proceed with implementing interventions
- C. establish client-centered, measurable & realistic outcomes
- D. determine priority of care & appropriate interventions
Correct Answer: A
Rationale: The correct answer is A because during evaluation, nurses must gather information about the client to identify whether client outcomes have been met. This step is crucial in determining the effectiveness of the care provided and if the client's needs have been addressed. Gathering this information helps in assessing the success of the interventions implemented.
Choice B is incorrect as organizing resources is part of the planning phase, not evaluation. Choice C is incorrect because establishing client-centered outcomes is part of the planning phase, not evaluation. Choice D is incorrect as determining priority of care and appropriate interventions is typically done during the assessment and planning phases, not evaluation.
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Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Requesting assistance when repositioning a client is crucial to prevent injury as it reduces the risk of strain on the nurse's body.
B: Avoiding twisting the spine or bending at the waist helps in maintaining proper body mechanics and prevents back injuries.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Summary of Incorrect Choices:
C: Keeping knees slightly lower than hips when sitting for long periods is related to ergonomics but not directly to preventing injury with client handling.
E: Taking breaks from repetitive movements every 2-3 hours is important for overall health but not specific to preventing injury with client handling.
Nurse educator is teaching module on proper body mechanics during employee orientation. Which statements by new nurse indicates need for more teaching?
- A. My line of gravity should fall outside my base of support
- B. The lower my center of gravity, the more stability I have
- C. To broaden my base of support, I should spread my feet apart
- D. When I lift an object, I should hold it as close to my body as possible
Correct Answer: A
Rationale: Rationale: A nurse's line of gravity should fall within the base of support, not outside, to maintain balance and prevent falls. Choice A is incorrect as it indicates a need for more teaching. Choices B, C, and D are correct statements that promote proper body mechanics. B explains the relationship between center of gravity and stability, C emphasizes broadening the base of support for better balance, and D suggests holding objects close to the body to reduce strain.
Nurse is reviewing safety precautions with group of young adults at community health fair. Which recommendations should nurse include specifically for this age group?
- A. "install bath rails & grab bars in bathrooms"
- B. wear helmet while skiing
- C. install carbon monoxide detector
- D. secure firearms in safe location
- E. remove throw rugs from the home
Correct Answer: B, C, D
Rationale: The correct recommendations for young adults are wearing a helmet while skiing (B), installing a carbon monoxide detector (C), and securing firearms in a safe location (D). Young adults are more likely to engage in high-risk activities like skiing, hence the importance of wearing a helmet (B). Carbon monoxide poisoning is a risk in any home, so installing a detector (C) is crucial for their safety. Securing firearms (D) is important as young adults may have access to them and need to prevent accidents or misuse. Choices A and E are more appropriate for older adults to prevent falls.
Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable and less fearful in the healthcare setting.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction, helping to alleviate fear and anxiety during procedures.
E: Engaging the child in pretend play with a toy medical kit allows for familiarization with medical tools in a non-threatening way, helping to reduce fear and anxiety related to medical procedures.
Summary:
B: Clustering invasive procedures may minimize the number of times the child needs to undergo such procedures but does not directly address the fear.
C: Assigning caregivers familiar to the child is important for comfort but may not directly address the fear of painful procedures.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.