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Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A: Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C: Turning pot handles toward the back of the stove reduces the risk of toddlers pulling them down. D: Placing safety gates across stairways prevents toddlers from falling down stairs. These strategies are crucial for accident prevention.
Incorrect choices: B: Keeping toilet seats up can lead to toddlers falling into the toilet. E: Making sure balloons are fully inflated increases the risk of choking hazards.
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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.
Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers causing the baby's symptoms.
C: Asking about specific foods helps pinpoint if a particular food is causing the issues.
D: Inquiring about vomiting helps assess if the baby's symptoms could be due to a more serious underlying issue.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding new foods without identifying the problem isn't ideal.
E: Not all babies react with indigestion to new foods, making this statement too general and not helpful in this case.
Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.)
- A. Building models
- B. Playing video games
- C. Reading books
- D. Using toy carpentry tools
- E. Shaping modeling clay
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. Building models (A) can enhance creativity and fine motor skills. Playing video games (B) can provide entertainment and cognitive stimulation. Reading books (C) promotes literacy and imagination. Using toy carpentry tools (D) may pose safety risks. Shaping modeling clay (E) is more suitable for younger children. No other choices are as developmentally appropriate and beneficial for school-age children as building models, playing video games, and reading books.
When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place?
- A. Client able to discuss appropriate technique
- B. Client able to demonstrate appropriate technique
- C. Client states he understands
- D. Client is able to write steps on piece of paper
Correct Answer: B
Rationale: The correct answer is B because demonstrating the appropriate technique shows psychomotor learning has taken place. This means the client can physically perform the actions involved in drawing up and mixing insulin injections. Merely discussing the technique (choice A) or stating understanding (choice C) doesn't necessarily mean the client can apply the knowledge in practice. Writing steps on paper (choice D) assesses cognitive understanding, not physical skill. In summary, the ability to physically demonstrate the technique is a direct indicator of psychomotor learning, making choice B the best option.
Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan?
- A. Irrigate affected area with running water
- B. Wash affected area with antibacterial soap
- C. Brush chemical off skin & clothing
- D. Apply neutralizing agent
Correct Answer: C
Rationale: The correct answer is C: Brush chemical off skin & clothing. This intervention is crucial to prevent further exposure and damage from the unknown chemical. By brushing off the chemical, the nurse can minimize the contact time and reduce the risk of more severe burns. Irrigating with water (choice A) may spread the chemical or react with it, worsening the burn. Washing with antibacterial soap (choice B) can also react with the chemical and cause more harm. Applying a neutralizing agent (choice D) can potentially worsen the burn if the wrong agent is used. Therefore, choice C is the best initial intervention to prevent further harm.