Nokea
Nurse observes smoke coming from under the door of the staff lounge. What is the priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The correct answer is C: Evacuate the clients. This is the priority action because ensuring the safety of the clients is the nurse's primary responsibility. Evacuating the clients from the area of potential danger is crucial to prevent harm. A: Extinguishing the fire should be left to trained personnel. B: Pulling the fire alarm is important, but evacuating clients takes precedence. D: Closing doors may help contain the fire but doesn't ensure immediate safety.
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A nurse is providing range of motion to the shoulder and must perform external rotation. Which action will the nurse take?
- A. Moves patient's arm in a full circle
- B. Moves patient's arm across the body as far as possible
- C. Moves patient's arm behind body, keeping elbow straight
- D. Moves patient's arm until thumb is upward and lateral to head with elbow flexed
Correct Answer: D
Rationale: The correct answer is D. To perform external rotation of the shoulder, the nurse should move the patient's arm until the thumb is upward and lateral to the head with the elbow flexed. This position optimally engages the external rotators of the shoulder joint, allowing for the desired movement. Choice A involves a full circle motion, which does not specifically target external rotation. Choice B focuses on adduction rather than external rotation. Choice C involves extension of the shoulder rather than external rotation. Therefore, the correct answer is D as it aligns with the anatomical movements required for external rotation of the shoulder joint.
Nurse at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children? (Select all that apply.)
- A. Childhood obesity
- B. Substance use disorders
- C. Scoliosis screening
- D. Front-seat seatbelt use
- E. Stranger awareness
Correct Answer: A,B,C,E
Rationale: The correct topics for parents of school-age children include childhood obesity, substance use disorders, scoliosis screening, and stranger awareness. A: Childhood obesity is relevant for promoting healthy lifestyles. B: Substance use disorders address risks children may face. C: Scoliosis screening is important for early detection. E: Stranger awareness educates on safety. Incorrect choices: D: Front-seat seatbelt use is more child-specific and not a primary concern for parents. F & G: Not provided in the question.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer from PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from PACU after thoracic surgery. RNs have the education and training to assess the client's condition, monitor vital signs, manage postoperative pain, and recognize any complications that may arise. They can also provide the necessary interventions and communicate effectively with the healthcare team. Assigning this client to an RN ensures safe and competent care.
Choice A (Charge nurse) may have administrative duties and may not be available to provide direct care. Choice C (LPN) may not have the scope of practice or training to manage postoperative care for a client following thoracic surgery. Choice D (AP) does not have the qualifications to assess and manage a client with complex postoperative needs.
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 toddlers should focus on their developmental needs. Filling & emptying containers (C) helps with sensory exploration and fine motor skills. Playing with blocks (D) enhances problem-solving and hand-eye coordination. Looking at books (E) promotes language development and cognitive skills. Building simple models (A) and working with clay (B) may not be suitable for toddlers due to potential choking hazards and fine motor skill requirements.
Nurse contributing to care plan for client being admitted to facility with suspected dx of pertussis. Which should nurse include in care plan?
- A. Place client in room with negative air pressure of at least 6 exchanges per hour
- B. Wear mask when providing care within 3 ft of client
- C. Place mask on client if transportation to another dept is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear gown when performing care that may result in contamination from secretions
Correct Answer: B,C,E
Rationale: The correct answer includes wearing a mask when providing care within 3 feet of the client to prevent the spread of pertussis through respiratory droplets. Placing a mask on the client during unavoidable transportation helps reduce exposure to others. Wearing a gown when performing care that may result in contamination from secretions is essential to prevent transmission through contact. Choice A is incorrect because negative air pressure is not necessary for pertussis isolation. Choice D is unnecessary as pertussis is not transmitted through contact with soiled linens.