Nokea
Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.)
- A. HPV
- B. Measles, mumps, rubella
- C. Varicella
- D. Haemophilus influenzae type b
- E. Polio
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. The nurse should include HPV, measles, mumps, rubella, and varicella in the discussion as these are recommended immunizations for young adults by the CDC. HPV vaccination helps prevent certain types of cancers and genital warts. Measles, mumps, and rubella vaccines protect against highly contagious diseases. Varicella vaccine prevents chickenpox. Choices D, E, F, and G are incorrect. Haemophilus influenzae type b and polio vaccines are typically given during infancy and childhood, not young adulthood. The options F and G are incomplete.
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Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the five rights of delegation?
- A. Right client
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E.
B: Right supervision/evaluation ensures proper oversight and assessment of tasks delegated.
C: Right direction/communication emphasizes clear instructions and effective communication.
E: Right circumstances require considering factors such as workload, staff competency, and patient condition.
A: Right client is not part of the five rights of delegation.
D: Right time is important but not specifically part of the five rights of delegation.
Nurse in clinic caring for 21-year-old client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The provider should perform this screening for a 21-year-old male as part of routine health maintenance. Testicular cancer is most common in young males, and early detection through a testicular exam is crucial for successful treatment. Blood glucose (B) screening is typically done for diabetes risk assessment, which is less likely in a young, asymptomatic individual. Fecal occult blood (C) screening is for colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (D) screening is for prostate cancer, which is rare in young males and not recommended without specific risk factors.
Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client is showing readiness to learn by asking a relevant question about the surgery process. This indicates an active interest in understanding what will happen during the procedure, which is crucial for preparing mentally and emotionally. Choice A is more focused on personal discomfort, not readiness to learn. Choice B is about pain management, not understanding the surgical process. Choice D is unrelated to the situation.