Nokea
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.
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Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information such as location, type of environment, and potential threats. By gathering this information discreetly, security personnel can better assess the situation and coordinate an appropriate response.
Choice A is incorrect because abruptly ending the call can hinder the ability to gather vital details. Choice B is incorrect as using overhead paging may cause panic and compromise safety. Choice C is incorrect because not asking questions can lead to missing important information.
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.
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.
Home health nurse is discussing dangers of food poisoning with client. Which info should nurse include in counseling? (Select all that apply.)
- A. Most food poisoning is caused by virus
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are especially at risk are instructed to eat/drink only pasteurized milk, yogurt, cheese, and other dairy products
- D. Healthy people usually recover from illness in few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Immunocompromised individuals have weakened immune systems, making them more susceptible to severe complications from food poisoning.
C: Clients at risk should consume only pasteurized dairy products to avoid harmful bacteria. Unpasteurized dairy can contain pathogens.
E: Separating raw and fresh foods prevents cross-contamination, reducing the risk of foodborne illnesses.
Incorrect:
A: Most food poisoning is caused by bacteria, not viruses.
D: Healthy individuals may recover faster, typically within a few days, not weeks.
Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.