Nokea
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.
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When entering client's room to change dressing
- A. nurse notes client is coughing & sneezing. When preparing sterile field
- B. it's important the nurse...
- C. Keep sterile field at least 6 ft away from client's bedside
- D. Instruct client to not cough/sneeze during dressing change
- E. Place mask on client to limit spread of microorganisms into surgical wound
Correct Answer: C
Rationale: The correct answer is C because keeping the sterile field at least 6 feet away from the client's bedside helps to maintain its integrity and prevent contamination. Placing the field further away reduces the risk of microorganisms reaching it during the dressing change procedure. Choice A is incorrect as the nurse should address the client's coughing and sneezing before proceeding with the dressing change. Choice B is vague and does not directly relate to maintaining sterility. Choice D is ineffective as instructing the client to stop coughing or sneezing is unrealistic. Choice E, while a good practice in general, does not directly address the maintenance of the sterile field.
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 prevents toddlers from accidentally pulling them down. D) Placing safety gates across stairways prevents toddlers from falling down stairs. B) Keeping toilet seats up increases the risk of toddlers falling in. E) Having balloons fully inflated poses a choking hazard. In summary, choices A, C, and D are important strategies for accident prevention, while choices B and E can actually increase risks for toddlers.
Nurse has prepared sterile field for assisting provider with chest tube insertion. Which should nurse recognize as contaminating sterile field?
- A. Provider drops sterile instrument onto near side of sterile field
- B. Nurse moistens cotton ball with sterile NS & places it on sterile field
- C. Procedure is delayed 1h because provider receives emergency call
- D. Nurse turns to speak to someone who enters through door behind nurse
- E. Client's hand brushes against outer edge of sterile field
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D.
B: Moistening a cotton ball with sterile NS and placing it on the sterile field introduces moisture and potentially non-sterile material, contaminating the field.
C: Delaying the procedure for an hour increases the risk of airborne contaminants settling on the sterile field.
D: Turning to speak to someone who enters behind the nurse can lead to inadvertent contact with non-sterile areas, contaminating the field.
Incorrect choices:
A: While dropping a sterile instrument close to the field is not ideal, it may not necessarily contaminate the field unless it actually touches it.
E: Client's hand brushing against the outer edge of the field is a potential contamination point, but it does not directly contaminate the sterile field.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. This position, known as orthopneic position, helps improve breathing by allowing the chest to expand fully, making it easier to take deep breaths. Sitting on the side of the bed and resting arms over pillows on a raised table helps to reduce the work of breathing.
A: Lie on my back with head & shoulders elevated on a pillow - This position may not provide as much relief in breathing as the orthopneic position.
B: Lie flat on my stomach with head to one side - This position can actually make breathing more difficult for someone with COPD.
D: Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me - This position may not be as effective in improving breathing compared to the orthopneic position.
By choosing option C, the client can effectively manage breathing difficulties associated with
The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
- A. Maintain a narrow base of support.
- B. Encourage the patient to dangle at the bedside.
- C. Encourage isometric exercises at the bedside.
- D. Suggest a high-calcium diet.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to dangle at the bedside. This is the first step in ambulating a patient who has been in bed for several days. Dangling helps prevent postural hypotension by allowing the patient's body to adjust gradually to an upright position. Maintaining a narrow base of support (A) is important during ambulation but comes after dangling. Isometric exercises (C) and suggesting a high-calcium diet (D) are not immediate actions needed for ambulation.