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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 following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.
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Nurse reviewing CDC's immunization recommendations with parents of 2 preschoolers. Which recommendations should nurse include in this discussion? (Select all that apply.)
- A. Haemophilus influenzae type b
- B. Varicella
- C. Polio
- D. Hepatitis A
- E. Seasonal influenza
Correct Answer: B,C,E
Rationale: The correct answers are B (Varicella), C (Polio), and E (Seasonal influenza). Varicella and seasonal influenza vaccines are recommended for preschoolers by the CDC to prevent the spread of these contagious diseases. Polio vaccine is important for preventing polio, a potentially serious disease that can be prevented through vaccination. Haemophilus influenzae type b, Hepatitis A, and the other choices are not typically part of the CDC's routine immunization recommendations for preschoolers. It is crucial for the nurse to include discussions on Varicella, Polio, and Seasonal influenza vaccines to ensure the children are protected from these preventable diseases.
Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.)
- A. Respiratory rate of 22/min with even, unlabored respirations
- B. I can only walk 3 blocks before my legs start to hurt'
- C. Pain level 3/10
- D. Skin pink, warm, dry
- E. Urine output 300 mL/8 hr
- F. Dressing clean, dry, intact
Correct Answer: A, D, E, F
Rationale: Objective data refers to measurable and observable information.
A: Respiratory rate and breathing pattern can be directly observed and counted, making it objective data.
D: Skin color, temperature, and moisture can be seen and felt, making it objective data.
E: Urine output is quantifiable and measurable, making it objective data.
F: The cleanliness, dryness, and integrity of a dressing can be visually assessed, making it objective data.
The other choices involve subjective experiences or interpretations (B), self-reported pain level (C), or may require additional assessments beyond direct observation (G).
Nurse manager of med-surg unit is assigning care responsibilities for oncoming shift. Client is awaiting transfer back to unit from PACU following thoracic surgery. To which staff member should nurse assign to this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. The Registered Nurse (RN) is the most appropriate staff member to care for the client awaiting transfer from PACU following thoracic surgery. RNs have the education, training, and scope of practice to assess, monitor, and provide specialized care for post-surgical patients. They can recognize and manage potential complications, administer medications, and coordinate the client's care effectively. Assigning the charge nurse (A) may compromise the overall management of the unit. LPNs (C) have a more limited scope of practice and may not have the necessary skills for post-surgical care. Assistive personnel (D) are not qualified to provide the level of care required for a client following thoracic surgery.
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 because determining what the client already knows about stress incontinence is essential for tailoring the instructional session effectively. By assessing the client's existing knowledge, the nurse can avoid repeating information that the client already understands and focus on areas where the client needs more education. This approach ensures that the session is individualized and meets the client's specific needs. Encouraging active participation (choice A) and setting goals (choice C) can come after assessing the client's knowledge. Selecting appropriate materials (choice B) is important but should be based on the client's knowledge level.
Nurse contributing to a care plan for a client being admitted to a facility with suspected pertussis. Which should the nurse include in the care plan? (Select all that apply.)
- A. Place client in a 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 department 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 answers are B, C, and E.
B: Wearing a mask within 3 ft of the client helps prevent the spread of pertussis, which is transmitted through respiratory secretions.
C: Placing a mask on the client during transportation reduces the risk of spreading the infection to others.
E: Wearing a gown during care that may result in contamination from secretions further prevents transmission.
A: Negative air pressure is not necessary for pertussis transmission control.
D: Sterile gloves are not required for handling soiled linens in pertussis cases.
In summary, the correct answers focus on preventing the spread of pertussis through respiratory secretions, while the incorrect choices are not directly related to infection control measures for this condition.