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Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.)
- A. Building models
- B. Playing video games
- C. Reading books
- D. Using toy carpentry tools
- E. Shaping modeling clay
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. Building models (A) can enhance creativity and fine motor skills. Playing video games (B) can provide entertainment and cognitive stimulation. Reading books (C) promotes literacy and imagination. Using toy carpentry tools (D) may pose safety risks. Shaping modeling clay (E) is more suitable for younger children. No other choices are as developmentally appropriate and beneficial for school-age children as building models, playing video games, and reading books.
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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 performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. "I already had my immunizations as a child
- B. so I'm protected in that area."
- C. It's important to schedule routine healthcare visits even if I'm feeling well.
- D. If I'm having any discomfort, I'll just go to an urgent care center.
- E. If I'm feeling stressed, I will remind myself that this is something I should expect.
Correct Answer: B
Rationale: The correct answer is B because the statement demonstrates an understanding of the importance of immunizations in preventing diseases. By acknowledging that immunizations from childhood offer protection, the client shows awareness of the role of vaccines in health promotion. Choice A only mentions past immunizations but does not indicate understanding of their ongoing importance. Choices C and D do not directly address health promotion or illness prevention. Choice E focuses on stress management rather than health maintenance.
When entering a client's room to change a dressing, the nurse notes the client is coughing & sneezing. When preparing a sterile field, it's important the nurse...
- A. Keep sterile field at least 6 ft away from client's bedside
- B. Instruct client to not cough/sneeze during dressing change
- C. Place mask on client to limit the spread of microorganisms into the surgical wound
- D. Keep box of Kleenex nearby for client to use during dressing change
Correct Answer: C
Rationale: The correct answer is C because placing a mask on the client helps limit the spread of microorganisms into the surgical wound. This is crucial to prevent infection. Choice A is incorrect because the distance does not necessarily prevent microorganism spread. Choice B is unrealistic as it's difficult for a client to control coughing/sneezing. Choice D does not address the prevention of microorganism spread.
Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)
- A. It might be good to add bananas, as they help with loose stools
- B. Let's make list of foods he's eating so we can spot problems
- C. Did the changes begin after you started 1 particular food?
- D. Has he been vomiting since he started these new foods?
- E. Most babies react with indigestion when you start new foods
Correct Answer: B,C,D
Rationale: Correct Answer: B, C, D
Rationale:
B: Making a list of foods eaten helps identify potential triggers causing the baby's symptoms.
C: Asking about specific foods helps pinpoint if a particular food is causing the issues.
D: Inquiring about vomiting helps assess if the baby's symptoms could be due to a more serious underlying issue.
Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding new foods without identifying the problem isn't ideal.
E: Not all babies react with indigestion to new foods, making this statement too general and not helpful in this case.