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Nurse is reviewing hand hygiene techniques with group of AP, which instructions should nurse include when discussing handwashing?
- 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 clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: The correct answers are B and D. Option B instructs to wash hands with soap and water for at least 15 seconds, which is recommended by CDC for thorough handwashing. Option D advises using a clean paper towel to turn off hand faucets to avoid recontaminating hands after washing. This is crucial to prevent the spread of germs.
Explanation for other choices:
A: Applying 3-5 mL of liquid soap to dry hands is not mentioned in hand hygiene guidelines.
C: Rinsing hands with hot water is not necessary and can actually be harmful to the skin.
E: Allowing hands to air dry is acceptable, but it is not a crucial instruction for handwashing.
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Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules, he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him because he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A. The nurse should identify the child's inability to keep up with other kids in physical activities as the priority for more assessment and intervention. This is because physical activity is crucial for a child's overall development and well-being. The inability to participate in activities like running and jumping could indicate underlying physical health issues, developmental delays, or coordination problems that need to be addressed promptly to prevent further complications. Choices B, C, and D are not as critical as they focus on behavioral or academic concerns which may be important but do not pose an immediate risk to the child's health and well-being.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct Answer: C
Rationale: The correct answer is C: Blood pressure cuff. To assess for orthostatic hypotension, the nurse needs to measure the patient's blood pressure in different positions - lying down, sitting, and standing. This is done using a blood pressure cuff to monitor any significant drop in blood pressure upon changing positions. A thermometer (choice A) is used to measure temperature and is not relevant to assessing orthostatic hypotension. Elastic stockings (choice B) are used for compression therapy in conditions like venous insufficiency and do not help in assessing orthostatic hypotension. Sequential compression devices (choice D) are used for preventing deep vein thrombosis and improving circulation, not for assessing orthostatic hypotension.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? Select all that apply
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Close all doors - By closing doors, the nurse can prevent the spread of smoke and fire, protecting patients.
B: Note evacuation routes - Knowing evacuation routes ensures a safe and efficient evacuation if needed.
C: Note oxygen shut-offs - Turning off oxygen can reduce the risk of fire spreading and explosions.
D: Move bedridden patients in their bed - Moving bedridden patients quickly and safely is crucial for their well-being during an emergency.
Summary:
E: Waiting for the fire department is not proactive and can waste valuable time in ensuring patient safety.
F: Using type B fire extinguishers for electrical fires is incorrect as type C extinguishers are recommended for electrical fires.
G: There is no information provided for this option.
Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?
- A. Client evaluates his behavior after social interaction
- B. Client states he is learning to trust others
- C. Client wishes to find meaningful relationships
- D. Client expresses concerns about next generation
Correct Answer: D
Rationale: The correct answer is D: Client expresses concerns about the next generation. This behavior aligns with Erikson's task of generativity vs. stagnation in middle adulthood. This stage involves contributing to future generations through mentoring, guiding, and caring for others. Expressing concerns about the next generation demonstrates a sense of responsibility and investment in the well-being of future individuals.
A: Evaluating behavior after social interaction pertains more to self-reflection and self-awareness, not specifically related to generativity.
B: Learning to trust others is more aligned with Erikson's earlier stage of trust vs. mistrust in infancy.
C: Wishing to find meaningful relationships is associated with Erikson's intimacy vs. isolation stage in young adulthood, not middle adulthood.
A nurse caring for a client with a new prescription checks the electronic database for medication information. Which component of critical thinking is the nurse using?
- A. Knowledge
- B. Experience
- C. Intuition
- D. Competence
Correct Answer: A
Rationale: The correct answer is A: Knowledge. Checking the electronic database for medication information involves accessing and utilizing factual information and data, which is a key component of knowledge in critical thinking. This process requires the nurse to gather relevant information, analyze it, and apply it to make informed decisions. Experience (B) and competence (D) are related to skills and proficiency but do not specifically focus on accessing information. Intuition (C) involves a gut feeling or instinct, which is different from actively seeking and using information.