Nurse preparing instructional session about managing stress...

Nurse preparing instructional session about managing stress incontinence for older adult. Which actions should nurse take first when meeting with client?

A. Encourage client to participate actively in learning
B. Select instructional materials appropriate for older adult
C. Identify goals nurse & client can agree are reasonable
D. Determine what client knows about stress incontinence

Correct Answer: D

Rationale: The correct answer is D: Determine what client knows about stress incontinence. This is the first step because it helps the nurse assess the client's baseline knowledge, tailor the information to their level of understanding, and avoid providing redundant information. Understanding the client's knowledge also helps to establish a starting point for education and to address any misconceptions. This approach promotes client-centered care and enhances the effectiveness of the educational session.

Choice A (Encourage client to participate actively in learning) is important but should come after assessing the client's knowledge. Choice B (Select instructional materials appropriate for older adult) is essential but should be based on the client's knowledge level. Choice C (Identify goals nurse & client can agree are reasonable) is important but should come after assessing the client's knowledge to set appropriate goals.

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.

When entering client's room to change dressing

A. nurse notes client is coughing & sneezing. When preparing sterile field
B. it's important the nurse...
C. Keep sterile field at least 6 ft away from client's bedside
D. Instruct client to not cough/sneeze during dressing change
E. Place mask on client to limit spread of microorganisms into surgical wound

Correct Answer: C

Rationale: The correct answer is C because keeping the sterile field at least 6 feet away from the client's bedside helps to maintain its integrity and prevent contamination. Placing the field further away reduces the risk of microorganisms reaching it during the dressing change procedure. Choice A is incorrect as the nurse should address the client's coughing and sneezing before proceeding with the dressing change. Choice B is vague and does not directly relate to maintaining sterility. Choice D is ineffective as instructing the client to stop coughing or sneezing is unrealistic. Choice E, while a good practice in general, does not directly address the maintenance of the sterile field.

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 is reviewing hand hygiene techniques with group of AP, which instructions should nurse include when discussing handwashing?

A. Apply 3-5 mL of liquid soap to dry hands
B. Wash hands with soap & water for at least 15 seconds
C. Rinse hands with hot water
D. Use clean paper towel to turn off hand faucets
E. Allow hands to air dry after washing

Correct Answer: B,D

Rationale: The correct answers are B and D. Option B instructs to wash hands with soap and water for at least 15 seconds, which is recommended by CDC for thorough handwashing. Option D advises using a clean paper towel to turn off hand faucets to avoid recontaminating hands after washing. This is crucial to prevent the spread of germs.
Explanation for other choices:
A: Applying 3-5 mL of liquid soap to dry hands is not mentioned in hand hygiene guidelines.
C: Rinsing hands with hot water is not necessary and can actually be harmful to the skin.
E: Allowing hands to air dry is acceptable, but it is not a crucial instruction for handwashing.

Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?

A. I already had my immunizations as a child, so I'm protected in that area.
B. It's important to schedule routine healthcare visits even if I'm feeling well
C. If I'm having any discomfort, I'll just go to an urgent care center
D. 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: It's important to schedule routine healthcare visits even if I'm feeling well. This statement indicates understanding of health promotion and illness prevention as it emphasizes the importance of preventive care and early detection of potential health issues. By attending routine healthcare visits, the individual can monitor their health status, receive necessary screenings, and address any underlying health concerns before they escalate.

Choice A is incorrect because having immunizations as a child does not provide lifelong protection against all diseases. Choice C is incorrect as urgent care centers are typically for urgent medical needs, not routine preventive care. Choice D is incorrect as stress management is important, but it does not directly relate to health promotion and illness prevention.