Nokea
Nurse reviewing carseat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include?
- A. Use car seat that has 3-point harness
- B. Position car seat so that infant is rear-facing
- C. Secure car seat in front passenger seat of car
- D. Put soft padding in car seat behind infants back & neck
Correct Answer: B
Rationale: The correct answer is B: Position car seat so that infant is rear-facing. This is important because rear-facing car seats are known to provide the best protection for infants in the event of a crash, as they support the head, neck, and spine. Other choices are incorrect because: A: A 3-point harness may not provide sufficient support for an infant's small body. C: Placing the car seat in the front passenger seat can be dangerous due to the presence of airbags. D: Soft padding can be a suffocation hazard and interfere with the proper fit of the harness.
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Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. Confidence
- B. Perseverance
- C. Integrity
- D. Discipline
Correct Answer: D
Rationale: The correct answer is D: Discipline. The nurse demonstrated discipline by using the head-to-toe approach, ensuring a systematic and thorough assessment. This approach helps in identifying any abnormalities or potential issues before surgery. Confidence (A) is important but not specific to the method used. Perseverance (B) and integrity (C) are valuable traits but not directly related to the assessment approach. The nurse's systematic and methodical approach reflects discipline, making it the most appropriate choice.
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.
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
- A. Increased appetite
- B. Increased diarrhea
- C. Increased metabolic rate
- D. Altered nutrient metabolism
Correct Answer: D
Rationale: The correct answer is D: Altered nutrient metabolism. Immobility can lead to changes in nutrient metabolism due to decreased physical activity and muscle mass. The body may start breaking down muscle tissue for energy, leading to altered nutrient metabolism.
A: Increased appetite is not directly related to immobility and is unlikely to be a metabolic alteration seen in this patient.
B: Increased diarrhea is more likely related to gastrointestinal issues rather than a direct metabolic alteration due to immobility.
C: Increased metabolic rate is unlikely in an immobile patient as physical activity is decreased.
Therefore, D is the correct choice as it directly relates to the metabolic changes associated with immobility.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.
A nurse is receiving a provider prescription by phone for morphine for a client who is reporting moderate to severe pain. Which of the following actions are appropriate?
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber's signature within 24 hours
- D. Decline verbal prescription because it is not an emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A,B,C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details of the prescription back to the provider ensures accuracy and reduces errors in transcription.
B: Having another nurse listen to the phone prescription provides a second verification to ensure accuracy and compliance with protocols.
C: Obtaining the prescriber's signature within 24 hours is necessary for legal documentation and accountability.
Summary:
Option D is incorrect because declining a verbal prescription in a non-emergency situation could delay necessary pain relief for the client. Option E is irrelevant to the immediate task of correctly processing the prescription.