Nokea
Nurse is reviewing hand hygiene techniques with a group of APs. Which instructions should the nurse include when discussing handwashing? (Select all that apply.)
- A. Apply 3-5 mL of liquid soap to dry hands
- B. Wash hands with soap & water for at least 15 seconds
- C. Rinse hands with hot water
- D. Use a clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: Correct Answer: B, D
Rationale:
B: Washing hands with soap & water for at least 15 seconds is crucial to ensure thorough cleaning and removal of germs.
D: Using a clean paper towel to turn off hand faucets helps prevent recontamination of clean hands.
Incorrect Choices:
A: Applying 3-5 mL of liquid soap to dry hands is not specified in handwashing guidelines.
C: Rinsing hands with hot water can strip the skin of natural oils and may not be necessary for effective hand hygiene.
E: Allowing hands to air dry after washing may not be sufficient to eliminate germs and is not a recommended step in hand hygiene protocols.
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Nurse admitting a client with acute cholecystitis to the med-surg unit. Which of the following actions are essential to the admission procedure? (Select all that apply.)
- 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: Correct Answer: A, B, C, E
Rationale:
A: Explaining roles of other care delivery staff helps manage client expectations and ensures effective communication among healthcare team members.
B: Beginning discharge planning early improves continuity of care and helps prevent delays in the discharge process.
C: Providing information about advance directives ensures the client's wishes are documented and respected in case of incapacitation.
E: Introducing the client to his roommate promotes social interaction and helps create a comfortable environment for the client.
Summary:
Choice D is incorrect as documenting organ donation wishes is not directly related to the admission process for acute cholecystitis.
Nurse reviewing car seat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include?
- A. Use car seat that has 3-point harness
- B. Position car seat so that infant is rear-facing
- C. Secure car seat in front passenger seat of car
- D. Put soft padding in car seat behind infant's back & neck
Correct Answer: B
Rationale: The correct answer is B: Position car seat so that infant is rear-facing. This is crucial for newborn safety as it reduces the risk of injury in the event of a crash. Rear-facing car seats provide optimal support for the infant's head, neck, and spine. Choice A is incorrect because a 5-point harness is recommended for infants for better protection. Choice C is incorrect as the back seat is the safest location for a car seat. Choice D is incorrect because soft padding can compress in a crash, leading to injury.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: Correct Answer: A,B,C,E
A: Helping the client see the benefits of their actions promotes motivation and adherence to health promotion strategies.
B: Identifying the client's support systems ensures they have a network to help maintain healthy behaviors and cope with stress.
C: Suggesting and recommending community resources expands the client's access to services that support cardiovascular health.
E: Teaching stress management strategies helps the client reduce risk factors associated with cardiovascular disease.
Incorrect Answer: D
Setting goals for the client without involving them in the process may not be effective in promoting long-term behavior change.
Nurse receives prescription for antibiotic for client with cellulitis. Nurse checks client's med record, discovers she's allergic to it, & calls provider to request different one. Which of following attitudes did the nurse demonstrate?
- A. fairness
- B. responsibility
- C. risk taking
- D. creativity
Correct Answer: B
Rationale: The correct answer is B: responsibility. The nurse demonstrated responsibility by ensuring patient safety and advocating for a suitable alternative antibiotic after discovering the allergy. This action aligns with the nurse's duty to provide safe and effective care.
Other choices are incorrect:
A: Fairness doesn't apply as the nurse's action was based on patient safety, not fairness.
C: Risk-taking is not demonstrated; the nurse acted based on known risks of the allergic reaction.
D: Creativity is not applicable here; the nurse followed standard protocols for managing allergies.
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. Because doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.