Nokea
Nurse is preparing discharge summary for client whose had knee surgery & is going home. Which following info about client should nurse include in it?
- A. Advance directives status
- B. Where to go for follow-up care
- C. Instructions for diet/meds
- D. Most recent vital sign data
- E. Contact info for home healthcare agency
- F. Follow-up care
- G. medication
Correct Answer: B,C,E
Rationale: The correct answer includes where to go for follow-up care, instructions for diet/meds, and contact info for home healthcare agency. Follow-up care ensures continuity of care post-surgery. Instructions for diet/meds are crucial for recovery. Contact info for home healthcare agency facilitates additional support at home. Advance directives status is important but not directly related to post-surgery care. Most recent vital sign data is essential for monitoring during hospitalization, not for discharge summary. Just mentioning follow-up care or medication without specific details is not as comprehensive as providing detailed instructions and contact information.
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A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
- A. Moves patient's arm in a full circle
- B. Moves patient's arm across the body as far as possible
- C. Moves patient's arm behind body, keeping elbow straight
- D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed
Correct Answer: D
Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.
Nurse talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I kind of like this girl in my class, but she doesn't like me back like that.
- B. I like hanging out with the guys in the science club, but the jocks pick on them.
- C. I just don't seem to be good at anything. I can't play sports at all.
- D. My dad wants me to be a lawyer like him, but I don't want to learn all that stuff
Correct Answer: C
Rationale: The correct answer is C because the adolescent's self-perception of not being good at anything can indicate low self-esteem and potential mental health concerns. This could impact their overall well-being and ability to cope with various stressors. Identifying and addressing self-esteem issues is crucial for their emotional development. Choices A, B, and D are not immediate priorities as they involve interpersonal relationships and career aspirations, which are important but not as urgent as addressing the adolescent's self-perception and mental health.
Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: The correct answers are A, B, and D.
A: Requesting assistance when repositioning a client is important to prevent injury as it reduces the risk of straining muscles or back injury.
B: Avoiding twisting the spine or bending at the waist helps maintain proper body mechanics and prevents strains.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Incorrect choices:
C: Keeping knees slightly lower than hips when sitting for long periods of time is not directly related to preventing injury with client care.
E: Taking breaks from repetitive movements every 2-3 hours to flex and stretch joints and muscles is important for general health but not specific to preventing injury in client care.
Nurse admitting client with acute cholecystitis to med-surg unit. Which of the following actions are essential to admission procedure?
- A. Explain roles of other care delivery staff
- B. Begin discharge planning
- C. Provide info about advance directives
- D. Document the client's wishes about organ donation
- E. Introduce client to his roommate
Correct Answer: A,B,C,E
Rationale: The correct choices (A, B, C, E) are essential for admission procedure. A is important to clarify roles of staff for effective care delivery. B is necessary to start discharge planning early for continuity of care. C ensures the client's preferences for future care are known. E helps the client feel comfortable by introducing them to their roommate. Choices D, F, and G are incorrect as they are not essential components of the admission procedure for acute cholecystitis.
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation?
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E.
B: Right supervision/evaluation ensures proper oversight and assessment of tasks delegated.
C: Right direction/communication emphasizes clear instructions and effective communication.
E: Right circumstances require considering factors such as workload, staff competency, and patient condition.
A: Right client is not part of the five rights of delegation.
D: Right time is important but not specifically part of the five rights of delegation.