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Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information such as location, type of environment, and potential threats. By gathering this information discreetly, security personnel can better assess the situation and coordinate an appropriate response.
Choice A is incorrect because abruptly ending the call can hinder the ability to gather vital details. Choice B is incorrect as using overhead paging may cause panic and compromise safety. Choice C is incorrect because not asking questions can lead to missing important information.
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Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.)
- A. Assembling puzzles
- B. Pulling wheeled toys
- C. Using musical toys
- D. Using finger paints
- E. Coloring with crayons
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. Preschoolers have developing fine motor skills and benefit from activities that promote hand-eye coordination and creativity. Assembling puzzles (A) helps with problem-solving and fine motor skills. Using musical toys (C) encourages creativity and sensory development. Coloring with crayons (E) promotes fine motor skills and creativity. Pulling wheeled toys (B) may not be appropriate for inpatient setting and finger paints (D) can be messy and require close supervision.
Nurse is caring for client sitting in chair & asks to return to bed. Which is priority action for nurse to take at this time?
- A. Obtain walker for client to use to transfer back to bed
- B. Call for additional personnel to assist with transfer
- C. Use transfer belt & assist client to bed
- D. Assess client's ability to help with transfer
Correct Answer: D
Rationale: The correct answer is D: Assess client's ability to help with transfer. The priority action for the nurse is to evaluate the client's capability to assist with the transfer safely. This assessment is crucial to prevent any potential injury to the client during the transfer process. By determining the client's ability to help, the nurse can make an informed decision on the level of assistance required.
Choice A (Obtain walker), B (Call for additional personnel), and C (Use transfer belt) are all important interventions but assessing the client's ability to help is the priority as it informs the next steps in the transfer process. Without knowing the client's capacity to assist, the nurse cannot effectively determine the appropriate interventions needed.
Overall, assessing the client's ability to help with the transfer ensures the safety and well-being of the client during the transfer process.
Client who will undergo neurosurgery in 1 week tells the nurse in office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands them?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead with the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C: "I plan to write that I don't want them to keep me on a breathing machine." This statement indicates understanding of advance directives as it demonstrates the client's specific wishes regarding life-sustaining treatment. By stating his preference clearly, the client shows he understands the purpose of advance directives in communicating his healthcare decisions.
Choice A: This indicates a lack of understanding as the client is unsure about who should make decisions for him, showing confusion about the purpose of advance directives.
Choice B: While this choice shows awareness of the importance of advance directives, it does not demonstrate understanding of the content or purpose of the document.
Choice D: Involving the regular doctor is not necessary for advance directives and does not indicate comprehension of the document's purpose.
In summary, choice C is correct as it directly addresses a specific healthcare decision, while the other choices do not demonstrate a clear understanding of advance directives.
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.
Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.