Nokea
Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: The correct answers are C and D.
C: The client scheduled for a TURP (transurethral resection of the prostate) can be safely discharged as this surgery is elective and not urgent.
D: The client who is 24 hours post-op after a mastectomy can also be discharged as they are stable and beyond the immediate post-operative phase.
A: Client receiving IV fluids for dehydration should not be discharged as they require ongoing treatment and monitoring.
B: Client with an NG tube for a small bowel obstruction should not be discharged as they require close observation and treatment.
E: Client scheduled for an appendectomy should not be discharged as this procedure is likely urgent and may require immediate attention.
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Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client? (Select all that apply.)
- A. Suggest his parents room in with him
- B. Provide a TV & DVDs for him to watch
- C. Limit visitors to immediate family
- D. Devise a regular schedule for inpatient routines
- E. Allow him to perform his own morning care
Correct Answer: B,E
Rationale: The correct choices are B and E. Providing a TV & DVDs and allowing the adolescent to perform his own morning care are appropriate interventions for the client's care. Offering entertainment can help with psychological well-being. Allowing independence in self-care promotes autonomy and self-esteem. Choice A may not be appropriate for an adolescent seeking independence. Choice C may restrict emotional support from close friends. Choice D is important but not the most crucial in this scenario.
Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct choices for the nurse to include in the discussion with the middle adult are Varicella, Herpes zoster, and Seasonal influenza. Varicella (chickenpox) and Herpes zoster (shingles) are important vaccinations to prevent these viral infections, especially in middle-aged adults who may be at higher risk. Seasonal influenza vaccination is also crucial for middle adults to protect against flu-related complications. Haemophilus influenzae type b is typically given to children under 5, so it is not relevant for this age group. HPV vaccination is recommended for younger individuals to prevent certain cancers.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. This is because at the age of 2, children often exhibit behaviors such as saying 'no' and resisting help as they start to assert their independence and autonomy. This behavior is a normal part of their development as they strive to explore their own abilities and assert control over their environment. Choices B, C, and D are incorrect because at this age, the child is not yet focused on developing a sense of trust, managing anger, or finishing projects. It is important to recognize and support the child's need for independence while providing guidance and setting appropriate boundaries.
Nurse educator is teaching module on proper body mechanics during employee orientation. Which statement by new nurse indicates need for more teaching?
- A. My line of gravity should fall outside my base of support
- B. The lower my center of gravity
- C. the more stability I have
- D. To broaden my base of support
- E. I should spread my feet apart
- F. I should hold it as close to my body as possible
Correct Answer: A
Rationale: Answer A is correct because the statement "My line of gravity should fall outside my base of support" indicates a misunderstanding of proper body mechanics. The line of gravity should fall within the base of support to maintain balance and prevent falls. Choices B, C, D, E, and F all reflect accurate understanding of body mechanics, emphasizing lowering the center of gravity, broadening the base of support, spreading feet apart for stability, and holding objects close to the body for leverage and control. Therefore, these choices do not indicate a need for more teaching.
Nurse caring for client just admitted after falling. This client is oriented x3 & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply)
- A. Place belt restraint on him when he's sitting on bedside commode
- B. Keep bed in low position with full side rails up
- C. Ensure client's call light is within reach
- D. Provide client with nonskid footwear
- E. Complete fall-risk assessment
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Ensuring client's call light is within reach allows the client to easily call for assistance, reducing the risk of attempting to get up independently and potentially falling.
D: Providing the client with nonskid footwear increases traction and stability, reducing the risk of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's risk of falling, allowing for tailored interventions to prevent falls.
Incorrect Choices:
A: Placing a belt restraint on the client when he's on the bedside commode is inappropriate as it restricts movement and can lead to increased agitation or attempts to remove the restraint, potentially causing a fall.
B: Keeping the bed in a low position with full side rails up can actually increase the risk of injury in case of a fall, as the client may try to climb over the rails or could become trapped between the rails and the bed.