Nokea
Nurse reviewing CDC's immunization recommendations with middle adult. Which should nurse include in this discussion?
- A. "Haemophilus influenzae type b"
- B. varicella
- C. herpes zoster
- D. HPV
- E. seasonal influenza
Correct Answer: B, C, E
Rationale: The correct answer includes varicella (B), herpes zoster (C), and seasonal influenza (E) because these vaccines are specifically recommended by the CDC for middle-aged adults. Varicella is important to prevent chickenpox, herpes zoster for shingles, and seasonal influenza to protect against the flu. Haemophilus influenzae type b (A) is typically given to children, HPV (D) is recommended for young adults, and there is no clear indication for choice F and G. It is crucial for the nurse to discuss vaccines that are relevant to the middle adult's age group to ensure they receive appropriate immunization protection.
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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 a toddler include filling & emptying containers (C) to promote sensory exploration, playing with blocks (D) for fine motor skills and spatial awareness, and looking at books (E) to encourage language development and cognitive skills. Building simple models (A) may be too complex for toddlers. Working with clay (B) can pose a choking hazard. The other options are not developmentally appropriate for toddlers.
Adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. Nurse believes that this is not in client's best interest, so she administers a PRN sedative medication that the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is confined or restrained against their will. In this scenario, the nurse's act of administering a sedative medication without the client's consent constitutes a form of restraint, therefore, it falls under false imprisonment. The nurse's action restricts the client's freedom to leave the hospital, even though the client is competent and has expressed the intention to leave. The other options are not applicable in this situation: A - Assault involves the threat of harm, C - Negligence involves a breach of duty of care, and D - Breach of confidentiality involves disclosing private information without consent.
Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Removing the crib gym is crucial as it can pose a choking hazard. Infants should sleep on a firm mattress to reduce the risk of suffocation, making option B incorrect. Option C is unsafe as soft pillows increase the risk of suffocation. Option D, while mentioning a safety gate, doesn't directly address infant safety.
Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.
A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP?
- A. Feeding client who was admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching w/ client who is learning to walk using quad cane
- C. Reapplying a condom catheter for client who has urinary incontinence
- D. Applying sterile dressing to pressure ulcer
Correct Answer: C
Rationale: The correct answer is C. The nurse can assign the task of reapplying a condom catheter for a client with urinary incontinence to an unlicensed assistive personnel (AP) because it is a routine, non-invasive procedure that does not require specialized nursing skills. The AP can be trained to perform this task safely under the nurse's supervision.
A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse.
B: Teaching a client to walk using a quad cane involves assessing the client's safety and gait, which should be done by a licensed nurse.
D: Applying a sterile dressing to a pressure ulcer requires knowledge of wound care principles and infection control, which should be done by a licensed nurse.