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.
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During evaluation
- A. the nurse must gather information about the client to...
- B. Identify whether client outcomes have been met
- C. Organize resources for interventions
- D. Establish client-centered
- E. measurable outcomes
Correct Answer: A
Rationale: The correct answer is A because during evaluation, the nurse needs to gather information about the client to assess the effectiveness of interventions and progress towards goals. This step involves collecting data to determine if the client's needs are being met and if adjustments are necessary. Option B is incorrect as it focuses on outcomes rather than the client's current status. Option C is incorrect as organizing resources is more related to planning than evaluation. Option D is incorrect as it pertains to establishing goals rather than evaluating progress. Option E is incorrect as it emphasizes measurable outcomes without considering the client's specific information needed for evaluation.
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.
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I spent my whole life dreaming about retirement, & now I wish I had my job back
- B. It's been so stressful for me to have to depend on my son to help around the house
- C. I just heard my friend Al died. That's the 3rd one in 3 months
- D. I'm struggling with helping out in my community. I just don't know what I can do
Correct Answer: D
Rationale: The correct answer is D. The priority issue for assessment & intervention is the older adult struggling with helping out in the community. This indicates a potential loss of purpose and meaning in life, which can negatively impact mental health. It may also suggest decreased social engagement, which is crucial for overall well-being in older adults. This issue requires immediate attention to prevent further decline in mental health and overall quality of life.
A: While feeling regret about retirement is important, it does not pose an immediate risk to the individual's well-being.
B: Depending on family for help is common in older age but does not indicate an urgent need for intervention.
C: Grieving the loss of friends is significant, but it may not be the priority issue for immediate intervention.
E, F, G: Choices are not provided, but they would likely be incorrect as they are not the priority issue for assessment & intervention.
A nurse is assessing body alignment. What is the nurse monitoring?
- A. The relationship of one body part to another while in different positions
- B. The coordinated efforts of the musculoskeletal and nervous systems
- C. The force that occurs in a direction to oppose movement
- D. The inability to move about freely
Correct Answer: A
Rationale: The correct answer is A. The nurse is monitoring the relationship of one body part to another while in different positions to ensure proper alignment. This is crucial for preventing musculoskeletal issues. Choice B refers to coordination, not body alignment. Choice C refers to resistance, not alignment. Choice D refers to immobility, not alignment.
Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct recommendations to include are Varicella (B), Polio (C), and Seasonal influenza (E). Varicella vaccination prevents chickenpox, a common childhood illness. Polio vaccination is crucial to prevent the spread of polio, a highly contagious disease that can cause paralysis. Seasonal influenza vaccination is recommended to protect against the flu, which can be severe in young children. Haemophilus influenzae type b (A) is typically given in infancy, not preschool years. Hepatitis A (D) is recommended for older children and high-risk groups, not necessarily preschoolers.