Nokea
Nurse reviewing CDC's immunizations recommendations with middle adult. Which should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct choices for the nurse to include in the discussion with the middle adult are Varicella, Herpes zoster, and Seasonal influenza. Varicella (chickenpox) and Herpes zoster (shingles) are important vaccinations to prevent these viral infections, especially in middle-aged adults who may be at higher risk. Seasonal influenza vaccination is also crucial for middle adults to protect against flu-related complications. Haemophilus influenzae type b is typically given to children under 5, so it is not relevant for this age group. HPV vaccination is recommended for younger individuals to prevent certain cancers.
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A nurse is assessing body alignment. What is the nurse monitoring?
- A. The relationship of one body part to another while in different positions
- B. The coordinated efforts of the musculoskeletal and nervous systems
- C. The force that occurs in a direction to oppose movement
- D. The inability to move about freely
Correct Answer: A
Rationale: The correct answer is A. The nurse is monitoring the relationship of one body part to another while in different positions to ensure proper alignment. This is crucial for preventing musculoskeletal issues. Choice B refers to coordination, not body alignment. Choice C refers to resistance, not alignment. Choice D refers to immobility, not alignment.
Nurse caring for client who reports severe sore throat
- A. pain with swallowing
- B. swollen lymph nodes. Client is experiencing which of following stages of infection?
- C. Prodromal
- D. Incubation
- E. Convalescence
Correct Answer: D
Rationale: The correct answer is D: Incubation. The client reporting a severe sore throat indicates that the infection is already present in the body but has not yet manifested with symptoms. During the incubation stage, the pathogen is actively multiplying but the client does not exhibit symptoms yet. Choices A, B, and C (pain with swallowing, swollen lymph nodes, and prodromal stage) all indicate that the infection has progressed beyond the incubation stage and symptoms are present. Choice E (Convalescence) refers to the period of recovery after the infection has been resolved, which is not the case here. Therefore, D is the correct answer as it corresponds to the stage where the client is experiencing symptoms without them being fully manifested yet.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an AP?
- A. Feeding client admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching with client learning to walk using a quad cane
- C. Reapplying a condom catheter for a client with urinary incontinence
- D. Applying sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C: Reapplying a condom catheter for a client with urinary incontinence. This task involves non-invasive, routine care that can be safely delegated to an assistive personnel (AP). The nurse should ensure that the AP is trained and competent in performing this procedure.
Choice A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse due to the risk of complications.
Choice B: Reinforcing teaching with a client using a quad cane involves critical thinking, assessment of the client's understanding, and ensuring safety, which should be done by a licensed nurse.
Choice D: Applying a sterile dressing to a pressure ulcer requires sterile technique, assessment of wound status, and potential need for wound care interventions, which should be performed by a licensed nurse.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? Select all that apply
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Close all doors - By closing doors, the nurse can prevent the spread of smoke and fire, protecting patients.
B: Note evacuation routes - Knowing evacuation routes ensures a safe and efficient evacuation if needed.
C: Note oxygen shut-offs - Turning off oxygen can reduce the risk of fire spreading and explosions.
D: Move bedridden patients in their bed - Moving bedridden patients quickly and safely is crucial for their well-being during an emergency.
Summary:
E: Waiting for the fire department is not proactive and can waste valuable time in ensuring patient safety.
F: Using type B fire extinguishers for electrical fires is incorrect as type C extinguishers are recommended for electrical fires.
G: There is no information provided for this option.
Nurse contributing to care plan for client being admitted to facility with suspected dx of pertussis. Which should nurse include in care plan?
- A. Place client in room with negative air pressure of at least 6 exchanges per hour
- B. Wear mask when providing care within 3 ft of client
- C. Place mask on client if transportation to another dept is unavoidable
- D. Use sterile gloves when handling soiled linens
- E. Wear gown when performing care that may result in contamination from secretions
Correct Answer: B,C,E
Rationale: The correct answer includes wearing a mask when providing care within 3 feet of the client to prevent the spread of pertussis through respiratory droplets. Placing a mask on the client during unavoidable transportation helps reduce exposure to others. Wearing a gown when performing care that may result in contamination from secretions is essential to prevent transmission through contact. Choice A is incorrect because negative air pressure is not necessary for pertussis isolation. Choice D is unnecessary as pertussis is not transmitted through contact with soiled linens.