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The charge nurse observes a student nurse administering a tuberculin skin test using the intradermal route. Which action by the student nurse requires intervention and additional teaching from the charge nurse?
- A. Advances tip of needle through epidermis until the bevel is no longer visible under the skin
- B. Chooses a 1-mL tuberculin syringe with a 27-gauge, 1/4-inch needle; dons clean gloves
- C. Injects medication slowly while raising a small wheal (bleb) on the skin
- D. Inserts needle at a 10-degree angle almost parallel to the skin with the bevel up
Correct Answer: A
Rationale: Advancing until the bevel is invisible (A) is too deep for intradermal injection, requiring intervention. Syringe choice (B), wheal formation (C), and angle (D) are correct.
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A nurse is providing a parenting class to individuals living in a community of older homes. In discussing formula preparation, which of the following is most important to prevent lead poisoning?
- A. Use ready-to-feed commercial infant formula
- B. Boil the tap water for 10 minutes prior to preparing the formula
- C. Let tap water run for 2 minutes before adding to concentrate
- D. Buy bottled water labeled 'lead free' to mix the formula
Correct Answer: C
Rationale: Use of lead-contaminated water to prepare formula is a major source of poisoning in infants. Letting tap water run for several minutes will diminish the lead contamination.
The nurse reinforces education about safety modifications in the home for the spouse of a client diagnosed with Alzheimer disease. What instructions should the nurse include?
- A. Arrange furniture to allow for free movement
- B. Keep frequently used items within easy reach
- C. Lock doors leading to stairwells and outside areas
- D. Place an identifying symbol on the bathroom door
- E. Provide a dark room free of shadows for sleeping
Correct Answer: A,B,C,D
Rationale: Clear pathways (A), accessible items (B), locked doors (C), and bathroom symbols (D) enhance safety. A dark room (E) may increase confusion or fear.
The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
- A. Repeatedly remind the client of the time and location
- B. Explain the risks of walking with no purpose
- C. Use protective devices to keep the client in the bed or chair in the room
- D. Attach a wander-guard sensor band to the client's wrist
Correct Answer: D
Rationale: This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?
- A. Right ventricle, left ventricle, right atrium, left atrium
- B. Left ventricle, right ventricle, left atrium, right atrium
- C. Right atrium, right ventricle, left atrium, left ventricle
- D. Right atrium, left atrium, right ventricle, left ventricle
Correct Answer: C
Rationale: Right atrium, right ventricle, left atrium, left ventricle. This is the correct pathway of blood flow through the heart.
A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first
- A. support the planning committee and post the new schedule
- B. explore how the planning committee evaluated barriers to the plan
- C. design a different approach to deliver care with fewer staff
- D. retain the previous staffing pattern for another 6 months
Correct Answer: B
Rationale: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated.