Nokea
Nurse Gayle is guided that the initial step of delegation is ______.
- A. demonstrate the task and let the staff continue the next activities
- B. Assess the capability of the staff, change him if not performing
- C. Determine the competency level of staff for the task being given
- D. Explain the task to be done with accompanying job description
Correct Answer: C
Rationale: The initial step of delegation is to determine the competency level of the staff for the task being given. Before delegating a task, a nurse must assess the knowledge, skills, and abilities of the staff member to ensure that they are competent and capable of performing the task safely and effectively. This step is crucial in ensuring that tasks are delegated appropriately and that quality patient care is maintained. By determining the competency level of the staff, Nurse Gayle can make informed decisions about delegation, provide appropriate support and resources, and facilitate effective communication throughout the delegation process.
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A patient presents with fever, malaise, and a skin lesion resembling a "bull's eye" rash at the site of a tick bite. Which of the following is the most likely causative agent?
- A. Plasmodium falciparum
- B. Trypanosoma cruzi
- C. Borrelia burgdorferi
- D. Leishmania donovani
Correct Answer: C
Rationale: The most likely causative agent in this scenario is Borrelia burgdorferi, which is the bacterium responsible for causing Lyme disease. The classic presentation of Lyme disease includes fever, malaise, and a skin lesion resembling a "bull's eye" rash, known as erythema migrans. This rash typically appears at the site of a tick bite. If left untreated, Lyme disease can progress to involve multiple organ systems and lead to more severe complications. Plasmodium falciparum is the causative agent of malaria, which typically presents with symptoms such as fever, chills, and fatigue, but it does not cause a "bull's eye" rash. Trypanosoma cruzi is the parasite responsible for Chagas disease, which presents with symptoms such as fever, swelling at the site of entry (typically the bite wound), and enlarged lymph nodes, but it does not
A woman in active labor requests hydrotherapy for pain relief. What is the nurse's priority action before initiating hydrotherapy?
- A. Obtain informed consent from the mother.
- B. Ensure that the labor room is equipped with a hydrotherapy tub.
- C. Assess the maternal and fetal conditions for eligibility.
- D. Review the mother's medical history for contraindications.
Correct Answer: C
Rationale: Before initiating hydrotherapy for pain relief during labor, the nurse's priority action should be to assess the maternal and fetal conditions to determine if the mother is eligible for this form of pain management. It is essential to ensure that hydrotherapy is safe and appropriate for the specific situation. Assessing the maternal condition includes evaluating factors such as the stage of labor, maternal and fetal well-being, and any medical conditions that could impact the use of hydrotherapy. This assessment helps to identify any contraindications or risks that may affect the mother and baby during hydrotherapy. By conducting a thorough assessment, the nurse can make an informed decision about whether hydrotherapy is suitable for the woman in labor.
Which of the following actions is appropriate for managing a conscious patient with a foreign object lodged in the eye?
- A. Attempting to remove the object with tweezers.
- B. Rinsing the eye with sterile saline solution.
- C. Applying pressure to the eyelid to dislodge the object.
- D. Placing a bandage over the affected eye.
Correct Answer: B
Rationale: When managing a conscious patient with a foreign object lodged in the eye, the appropriate action is to rinse the eye with sterile saline solution. This helps to flush out the foreign object and reduce the risk of further injury or infection. Attempting to remove the object with tweezers or applying pressure to the eyelid can potentially cause more harm to the eye. Placing a bandage over the affected eye is not beneficial in this situation as it does not address the presence of the foreign object. Rinsing the eye with sterile saline solution is the safest and most effective initial step to take in managing a foreign object lodged in the eye.
A postpartum client who delivered twins expresses concerns about breastfeeding both infants simultaneously. What nursing intervention should be prioritized to address the client's concerns?
- A. Demonstrating tandem breastfeeding positions and techniques
- B. Recommending the use of nipple shields to facilitate latch for both infants
- C. Encouraging the client to alternate breastfeeding sessions between the infants
- D. Referring the client to a lactation consultant for assistance
Correct Answer: A
Rationale: Demonstrating tandem breastfeeding positions and techniques should be prioritized as the nursing intervention to address the client's concerns about breastfeeding both infants simultaneously. Tandem breastfeeding involves nursing twins at the same time and can help enhance milk production, promote bonding with both infants, and save time for the mother. By showing the client the proper positions and techniques for tandem breastfeeding, the nurse can empower the client with the knowledge and skills needed to successfully breastfeed both infants together. This intervention can ultimately support the client in feeling more confident and competent in managing the challenges of breastfeeding twins.
In planning for Jose's oxygen therapy, the nurse shall consider which of the following, EXCEPT
- A. need for a humidifier.
- B. length of tubing.
- C. determine the age of Jose.
- D. manner of administering oxygen, continuous or intermittent.
Correct Answer: C
Rationale: When planning for Jose's oxygen therapy, the nurse should consider the need for a humidifier to prevent drying of the mucous membranes, the appropriate length of tubing for mobility and safety reasons, and the manner of administering oxygen (continuous or intermittent) based on Jose's condition and oxygen requirements. However, determining Jose's age is not a relevant factor in planning for his oxygen therapy. The decision-making process should be based on his specific medical needs and condition rather than his age.