Nurse educator is teaching module on proper body mechanics during employee orientation. Which statement 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
- C. the more stability I have
- D. To broaden my base of support
- E. I should spread my feet apart
- F. I should hold it as close to my body as possible
Correct Answer: A
Rationale: Answer A is correct because the statement "My line of gravity should fall outside my base of support" indicates a misunderstanding of proper body mechanics. The line of gravity should fall within the base of support to maintain balance and prevent falls. Choices B, C, D, E, and F all reflect accurate understanding of body mechanics, emphasizing lowering the center of gravity, broadening the base of support, spreading feet apart for stability, and holding objects close to the body for leverage and control. Therefore, these choices do not indicate a need for more teaching.
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A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer from PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from PACU after thoracic surgery. RNs have the education and training to assess the client's condition, monitor vital signs, manage postoperative pain, and recognize any complications that may arise. They can also provide the necessary interventions and communicate effectively with the healthcare team. Assigning this client to an RN ensures safe and competent care.
Choice A (Charge nurse) may have administrative duties and may not be available to provide direct care. Choice C (LPN) may not have the scope of practice or training to manage postoperative care for a client following thoracic surgery. Choice D (AP) does not have the qualifications to assess and manage a client with complex postoperative needs.
Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.)
- A. Metabolism
- B. Ability to hear low-pitched sounds
- C. Gastric secretion
- D. Far vision
- E. Glomerular filtration
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. As individuals age, metabolism decreases due to changes in muscle mass and activity levels. Gastric secretion decreases, leading to decreased absorption of certain nutrients. Glomerular filtration rate decreases with age, affecting kidney function. Choice B is incorrect as hearing high-pitched sounds is more commonly affected with age. Choice D is incorrect as near vision is usually affected, not far vision.
A nursing instructor is reviewing actions nurses can initiate without a provider's prescription. Which of the following are nurse-initiated?
- A. Give morphine 1-2 mg IV every 1h as needed
- B. Insert NG tube to relieve gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C,D,E
Rationale: The correct answers are C, D, and E. C: Nurses can educate clients on progressive muscle relaxation techniques without a prescription to promote relaxation. D: Providing daily baths is part of basic hygiene care and can be initiated by nurses without a prescription. E: Repositioning clients every 2 hours to prevent pressure ulcers is within the scope of nursing practice. A: Administering morphine requires a prescription due to the potential for adverse effects. B: Inserting an NG tube involves a medical procedure and should be prescribed by a provider.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. This position, known as orthopneic position, helps improve breathing by allowing the chest to expand fully, making it easier to take deep breaths. Sitting on the side of the bed and resting arms over pillows on a raised table helps to reduce the work of breathing.
A: Lie on my back with head & shoulders elevated on a pillow - This position may not provide as much relief in breathing as the orthopneic position.
B: Lie flat on my stomach with head to one side - This position can actually make breathing more difficult for someone with COPD.
D: Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me - This position may not be as effective in improving breathing compared to the orthopneic position.
By choosing option C, the client can effectively manage breathing difficulties associated with
Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?
- A. Client evaluates his behavior after social interaction
- B. Client states he is learning to trust others
- C. Client wishes to find meaningful relationships
- D. Client expresses concerns about next generation
Correct Answer: D
Rationale: The correct answer is D: Client expresses concerns about the next generation. This behavior aligns with Erikson's task of generativity vs. stagnation in middle adulthood. This stage involves contributing to future generations through mentoring, guiding, and caring for others. Expressing concerns about the next generation demonstrates a sense of responsibility and investment in the well-being of future individuals.
A: Evaluating behavior after social interaction pertains more to self-reflection and self-awareness, not specifically related to generativity.
B: Learning to trust others is more aligned with Erikson's earlier stage of trust vs. mistrust in infancy.
C: Wishing to find meaningful relationships is associated with Erikson's intimacy vs. isolation stage in young adulthood, not middle adulthood.