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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:
1. Crib gyms can pose a suffocation risk for infants, so removing it shows understanding of safety.
2. Soft mattresses increase the risk of Sudden Infant Death Syndrome.
3. Fluffy pillows pose suffocation hazard; infants should sleep on a firm, flat surface.
4. Child-safety gates should not fold like accordions as they can trap fingers.
Summary:
B and C pose suffocation risks. D is incorrect as accordion-style gates can be hazardous. A demonstrates understanding of infant safety by removing the crib gym.
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Nurse in clinic caring for 21-year-old client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The provider should perform this screening for a 21-year-old male as part of routine health maintenance. Testicular cancer is most common in young males, and early detection through a testicular exam is crucial for successful treatment. Blood glucose (B) screening is typically done for diabetes risk assessment, which is less likely in a young, asymptomatic individual. Fecal occult blood (C) screening is for colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (D) screening is for prostate cancer, which is rare in young males and not recommended without specific risk factors.
When entering client's room to change dressing
- A. nurse notes client is coughing & sneezing. When preparing sterile field
- B. it's important the nurse...
- C. Keep sterile field at least 6 ft away from client's bedside
- D. Instruct client to not cough/sneeze during dressing change
- E. Place mask on client to limit spread of microorganisms into surgical wound
Correct Answer: C
Rationale: The correct answer is C because keeping the sterile field at least 6 feet away from the client's bedside helps to maintain its integrity and prevent contamination. Placing the field further away reduces the risk of microorganisms reaching it during the dressing change procedure. Choice A is incorrect as the nurse should address the client's coughing and sneezing before proceeding with the dressing change. Choice B is vague and does not directly relate to maintaining sterility. Choice D is ineffective as instructing the client to stop coughing or sneezing is unrealistic. Choice E, while a good practice in general, does not directly address the maintenance of the sterile field.
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: The correct answers are A, B, and D.
A: Requesting assistance when repositioning a client is important to prevent injury as it reduces the risk of straining muscles or back injury.
B: Avoiding twisting the spine or bending at the waist helps maintain proper body mechanics and prevents strains.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Incorrect choices:
C: Keeping knees slightly lower than hips when sitting for long periods of time is not directly related to preventing injury with client care.
E: Taking breaks from repetitive movements every 2-3 hours to flex and stretch joints and muscles is important for general health but not specific to preventing injury in client care.
Nurse providing discharge instructions to client with a prescription for oxygen use at home. What should the nurse teach about using oxygen safely? (Select all that apply)
- A. Family members who smoke must be at least 10 ft from client when oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish shouldn't be used near client receiving oxygen to prevent flammability risk as it contains volatile chemicals that can ignite.
C: A 'No Smoking' sign should be placed on the front door to remind visitors and family members to not smoke near oxygen, reducing fire risk.
E: Fire extinguisher should be readily available in the home to quickly address any potential fires related to oxygen use, ensuring safety.
Summary:
A: Keeping family members who smoke at least 10 ft away is important, but not the most critical safety measure.
D: Replacing cotton with wool clothing does not directly impact oxygen safety.
F & G: No information provided.
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion? (Select all that apply.)
- A. Rotavirus
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. Varicella (B) vaccine is recommended for adolescents who haven't been vaccinated before. HPV (D) vaccine is crucial for preventing certain types of cancers. Seasonal influenza (E) vaccine helps protect against the flu, which can be severe. Rotavirus (A) vaccine is typically given to infants, not adolescents. Herpes zoster (C) vaccine is for adults over 50. No information is given for choices F and G.