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Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Removing the crib gym is crucial as it can pose a choking hazard. Infants should sleep on a firm mattress to reduce the risk of suffocation, making option B incorrect. Option C is unsafe as soft pillows increase the risk of suffocation. Option D, while mentioning a safety gate, doesn't directly address infant safety.
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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 is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A: Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C: Turning pot handles toward the back of the stove reduces the risk of toddlers pulling them down. D: Placing safety gates across stairways prevents toddlers from falling down stairs. These strategies are crucial for accident prevention.
Incorrect choices: B: Keeping toilet seats up can lead to toddlers falling into the toilet. E: Making sure balloons are fully inflated increases the risk of choking hazards.
Nurse performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.
Client who will undergo neurosurgery in 1 week tells the nurse in office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands them?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead with the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C: "I plan to write that I don't want them to keep me on a breathing machine." This statement indicates understanding of advance directives as it demonstrates the client's specific wishes regarding life-sustaining treatment. By stating his preference clearly, the client shows he understands the purpose of advance directives in communicating his healthcare decisions.
Choice A: This indicates a lack of understanding as the client is unsure about who should make decisions for him, showing confusion about the purpose of advance directives.
Choice B: While this choice shows awareness of the importance of advance directives, it does not demonstrate understanding of the content or purpose of the document.
Choice D: Involving the regular doctor is not necessary for advance directives and does not indicate comprehension of the document's purpose.
In summary, choice C is correct as it directly addresses a specific healthcare decision, while the other choices do not demonstrate a clear understanding of advance directives.
Nurse is caring for client sitting in chair & asks to return to bed. Which is priority action for nurse to take at this time?
- A. Obtain walker for client to use to transfer back to bed
- B. Call for additional personnel to assist with transfer
- C. Use transfer belt & assist client to bed
- D. Assess client's ability to help with transfer
Correct Answer: D
Rationale: The correct answer is D: Assess client's ability to help with transfer. The priority action for the nurse is to evaluate the client's capability to assist with the transfer safely. This assessment is crucial to prevent any potential injury to the client during the transfer process. By determining the client's ability to help, the nurse can make an informed decision on the level of assistance required.
Choice A (Obtain walker), B (Call for additional personnel), and C (Use transfer belt) are all important interventions but assessing the client's ability to help is the priority as it informs the next steps in the transfer process. Without knowing the client's capacity to assist, the nurse cannot effectively determine the appropriate interventions needed.
Overall, assessing the client's ability to help with the transfer ensures the safety and well-being of the client during the transfer process.