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Nurse has removed sterile pack from its outside cover & placed it on clean work surface in prep for invasive procedure. Which of following flaps should nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. The rationale is to maintain sterility. By unfolding the flap farthest from the body first, the nurse can avoid reaching over the sterile field, minimizing the risk of contamination. This step-by-step approach ensures that the sterile pack remains uncontaminated and ready for the invasive procedure. Unfolding the closest flap, right side flap, or left side flap first would require the nurse to lean over the sterile field, increasing the chances of contamination. Therefore, choosing the flap farthest from the body is the most logical and sterile technique in this situation.
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A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
- A. Increased appetite
- B. Increased diarrhea
- C. Increased metabolic rate
- D. Altered nutrient metabolism
Correct Answer: D
Rationale: The correct answer is D: Altered nutrient metabolism. Immobility can lead to changes in nutrient metabolism due to decreased physical activity and muscle mass. The body may start breaking down muscle tissue for energy, leading to altered nutrient metabolism.
A: Increased appetite is not directly related to immobility and is unlikely to be a metabolic alteration seen in this patient.
B: Increased diarrhea is more likely related to gastrointestinal issues rather than a direct metabolic alteration due to immobility.
C: Increased metabolic rate is unlikely in an immobile patient as physical activity is decreased.
Therefore, D is the correct choice as it directly relates to the metabolic changes associated with immobility.
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. I already had my immunizations as a child, so I'm protected in that area.
- B. It's important to schedule routine healthcare visits even if I'm feeling well
- C. If I'm having any discomfort, I'll just go to an urgent care center
- D. If I'm feeling stressed, I will remind myself that this is something I should expect
Correct Answer: B
Rationale: The correct answer is B: It's important to schedule routine healthcare visits even if I'm feeling well. This statement indicates understanding of health promotion and illness prevention as it emphasizes the importance of preventive care and early detection of potential health issues. By attending routine healthcare visits, the individual can monitor their health status, receive necessary screenings, and address any underlying health concerns before they escalate.
Choice A is incorrect because having immunizations as a child does not provide lifelong protection against all diseases. Choice C is incorrect as urgent care centers are typically for urgent medical needs, not routine preventive care. Choice D is incorrect as stress management is important, but it does not directly relate to health promotion and illness prevention.
Nurse wearing sterile gloves in prep for performing sterile procedure. Which of following objects may nurse touch without breaching sterile technique?
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. 1 gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: The correct choices are C, D, and E. The nurse can touch the inner wrapping of an item on the sterile field because it is considered sterile. The nurse can touch the irrigation syringe on the sterile field as long as it is also considered sterile and part of the field. The nurse can also touch one gloved hand with the other gloved hand, as the gloves are considered sterile. Choices A and B are incorrect because touching the bottle or the edge of the drape would breach sterile technique.
A nurse receives a prescription for an antibiotic for a client with cellulitis. Upon review
- A. the nurse finds the client is allergic and calls the provider. Which attitude does the nurse demonstrate?
- B. Fairness
- C. Responsibility
- D. Risk taking
- E. Creativity
Correct Answer: B
Rationale: The correct answer is B: Fairness. The nurse demonstrates fairness by acknowledging the client's allergy and taking the necessary steps to address it, ensuring the client's safety and well-being. Responsibility (C) could also be a consideration, but fairness is more directly related to this specific scenario. Risk taking (D) and Creativity (E) are not relevant in this situation as the nurse's actions are based on standard protocols and patient safety.
Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct recommendations to include are Varicella (B), Polio (C), and Seasonal influenza (E). Varicella vaccination prevents chickenpox, a common childhood illness. Polio vaccination is crucial to prevent the spread of polio, a highly contagious disease that can cause paralysis. Seasonal influenza vaccination is recommended to protect against the flu, which can be severe in young children. Haemophilus influenzae type b (A) is typically given in infancy, not preschool years. Hepatitis A (D) is recommended for older children and high-risk groups, not necessarily preschoolers.