Nokea
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: Correct Answer: A, B, D
Rationale:
A: Requesting assistance when repositioning a client is crucial to prevent injury as it reduces the risk of strain on the nurse's body.
B: Avoiding twisting the spine or bending at the waist helps in maintaining proper body mechanics and prevents back injuries.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Summary of Incorrect Choices:
C: Keeping knees slightly lower than hips when sitting for long periods is related to ergonomics but not directly to preventing injury with client handling.
E: Taking breaks from repetitive movements every 2-3 hours is important for overall health but not specific to preventing injury with client handling.
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Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.)
- A. Building simple models
- B. Working with clay
- C. Filling & emptying containers
- D. Playing with blocks
- E. Looking at books
Correct Answer: C,D,E
Rationale: The correct activities for a toddler include filling & emptying containers (C) to promote sensory exploration, playing with blocks (D) for fine motor skills and spatial awareness, and looking at books (E) to encourage language development and cognitive skills. Building simple models (A) may be too complex for toddlers. Working with clay (B) can pose a choking hazard. The other options are not developmentally appropriate for toddlers.
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 wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.)
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. One gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: The nurse can touch the inner wrapping of an item on the sterile field because it is considered part of the sterile field and does not compromise the sterility.
D: The nurse can touch the irrigation syringe on the sterile field as it is within the sterile field and maintaining sterility.
E: The nurse can touch one gloved hand with the other gloved hand as long as both hands are sterile.
Summary:
A: Incorrect - Nurse should not touch a bottle containing sterile solution as it is not part of the sterile field.
B: Incorrect - Nurse should avoid touching the edge of a sterile drape at the base of the field as it is considered unsterile.
F & G: Not applicable.
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 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 answers are B (Varicella), C (Polio), and E (Seasonal influenza). Varicella and seasonal influenza vaccines are recommended for preschoolers by the CDC to prevent the spread of these contagious diseases. Polio vaccine is important for preventing polio, a potentially serious disease that can be prevented through vaccination. Haemophilus influenzae type b, Hepatitis A, and the other choices are not typically part of the CDC's routine immunization recommendations for preschoolers. It is crucial for the nurse to include discussions on Varicella, Polio, and Seasonal influenza vaccines to ensure the children are protected from these preventable diseases.