Nokea
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.
You may also like to solve these questions
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? Select all that apply
- A. One family member has gone to lunch.
- B. Patient is placed in bilateral wrist restraints at 0815.
- C. Bilateral radial pulses present, 2+, hands warm to touch
- D. Straps with quick-release buckle attached to bed side rails
- E. Attempts to distract the patient with television are unsuccessful.
- F. Released from restraints, active range-of-motion exercises completed.
Correct Answer: B, C, E, F
Rationale: The correct answers are B, C, E, and F.
B: Documenting the time and type of restraints applied is essential for monitoring and ensuring proper care.
C: Assessing and documenting the patient's radial pulses and skin temperature in restraints is crucial to monitor circulation and skin integrity.
E: Documenting unsuccessful attempts to distract the patient with television helps identify alternative strategies for patient management.
F: Documenting the release from restraints and completion of range-of-motion exercises ensures proper follow-up care and monitoring.
Incorrect choices:
A: Not relevant to the patient's care in restraints.
D: Describes the equipment used but does not provide information on the patient's condition or care.
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.
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct Answer: C
Rationale: The correct answer is C: Blood pressure cuff. To assess for orthostatic hypotension, the nurse needs to measure the patient's blood pressure in different positions - lying down, sitting, and standing. This is done using a blood pressure cuff to monitor any significant drop in blood pressure upon changing positions. A thermometer (choice A) is used to measure temperature and is not relevant to assessing orthostatic hypotension. Elastic stockings (choice B) are used for compression therapy in conditions like venous insufficiency and do not help in assessing orthostatic hypotension. Sequential compression devices (choice D) are used for preventing deep vein thrombosis and improving circulation, not for assessing orthostatic hypotension.
As part of admission process
- A. nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family?
- B. BMI
- C. Usual times for meals/snacks
- D. Favorite foods
- E. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Favorite foods. This is because knowing the client's favorite foods is crucial in ensuring they receive proper nutrition and enjoy their meals, especially for someone with dementia who may have difficulty remembering or expressing preferences. It helps enhance their quality of life and promotes adequate food intake.
Other choices are less critical:
A: Nutrition history can include various components, not just family input.
B: BMI is important but not the priority when gathering nutrition information.
C: Knowing meal/snack times is relevant but not as crucial as favorite foods.
E: Swallowing difficulty is important but not the priority in this scenario.
Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.)
- A. HPV
- B. Measles, mumps, rubella
- C. Varicella
- D. Haemophilus influenzae type b
- E. Polio
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. The nurse should include HPV, measles, mumps, rubella, and varicella in the discussion as these are recommended immunizations for young adults by the CDC. HPV vaccination helps prevent certain types of cancers and genital warts. Measles, mumps, and rubella vaccines protect against highly contagious diseases. Varicella vaccine prevents chickenpox. Choices D, E, F, and G are incorrect. Haemophilus influenzae type b and polio vaccines are typically given during infancy and childhood, not young adulthood. The options F and G are incomplete.