Nokea
The charge nurse is observing nursing staff. In which activity illustrated should the charge nurse intervene because it places the nurse most at risk for back injury?
- A. intervene_1.PNG
- B. intervene_2.PNG
- C. intervene_3.PNG
- D. intervene_4.PNG
Correct Answer: D
Rationale: Bending and twisting the torso, as described in option D, poses the highest risk for back injury due to improper body mechanics, even with a transfer belt. The client's potential to grab the nurse's shoulder or arm increases the risk by destabilizing the nurse's stance.
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Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. disability prevention.
Correct Answer: B
Rationale: The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.
After an explosion at a factory one of the employees approaches the nurse and says 'I am an unlicensed assistive personnel (UAP) at the local hospital.' Which of these tasks should the nurse assign first to this worker who wants to help care for the wounded workers?
- A. Get temperatures
- B. Take blood pressure
- C. Palpate pulses
- D. Check alertness
Correct Answer: C
Rationale: Palpate pulses. The heart rates would indicate if the client is in shock or has potential for shock. If the pulses could not be palpated, those clients would need to be seen first.
What does client and family communication and education concerning restraints do?
- A. confuses both groups more
- B. helps with coping and stress levels
- C. encourages cooperation with the client and family
- D. puts the responsibility on the client and family, not the nurse
Correct Answer: C
Rationale: Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints. Well-meaning family members might release restraints if their purpose is not clear.
Which of these actions should the nurse perform first when a client is admitted with a diagnosis of C-difficile?
- A. Initiate contact precautions
- B. Administer prescribed antibiotics
- C. Obtain a stool culture
- D. Educate the client about hand hygiene
Correct Answer: A
Rationale: Initiating contact precautions is the first step to prevent the spread of C-difficile, which is highly contagious through contact with contaminated surfaces or feces.
The nurse seeks to assess the renal function of an elderly client who is about to receive a nephrotoxic medication. Which of the following labs provides the best indicator for renal function?
- A. urinalysis
- B. creatinine and blood urea nitrogen
- C. chemistry of electrolytes
- D. creatinine clearance
Correct Answer: D
Rationale: Due to decreases in lean body mass, blood creatinine is not as good an indicator of the elderly client's renal function as creatinine clearance. Creatinine clearance is a widely used test for glomerular filtration rate.