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How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
- A. 1 foot
- B. 2 feet
- C. 4 feet
- D. 6 feet
Correct Answer: D
Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger.
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Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. disability prevention.
Correct Answer: B
Rationale: The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.
The charge nurse is planning assignments on a medical unit. Which client should be assigned to the practical nurse (PN)?
- A. Test a stool specimen for occult blood
- B. Assist with the ambulation of a client with a chest tube system
- C. Irrigate and redress a leg wound
- D. Admit a client from the emergency room
Correct Answer: C
Rationale: The PN is a licensed provider and can perform this complex task. Irrigating and redressing a leg wound requires clinical skills appropriate for a PN, whereas the other tasks are either simpler or require an RN.
The nurse is planning an educational session for a group of parents with toddlers. Based on the two leading causes of death in toddlers, the nurse should make which topics priority? Select all that apply.
- A. Water safety and methods to prevent drowning.
- B. Use of age- and weight-appropriate car seats.
- C. Nutrition guidelines and age-appropriate foods.
- D. Use of labels to identify poisonous substances.
- E. Safety when outdoors and crossing the street.
Correct Answer: A,B
Rationale: Drowning and motor vehicle accidents are the top two causes of death in toddlers, making water safety and car seat use priority topics.
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
- A. Formula or breast milk
- B. Dilute nonfat dry milk
- C. Warmed fruit juice
- D. Fluoridated tap water
Correct Answer: A
Rationale: Formula or breast milk. Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.