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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.
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Nurse has noticed several times in past week when another nurse on unit seemed drowsy & unable to focus. Today, she found nurse asleep in chair in break room when she was not on a break. Which of the following actions should nurse take?
- A. Remind nurse that safe client care is priority on unit
- B. Ask others on team whether they have seen same behavior
- C. Report observations to nurse manager on unit
- D. Conclude her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct answer is C: Report observations to nurse manager on unit. This is the best course of action as it prioritizes patient safety and addresses the potential risk of a drowsy and unfocused nurse providing care. Reporting to the nurse manager is important to ensure proper intervention and support for the drowsy nurse.
Choice A: Reminding the nurse of safe client care is important but does not address the root cause of the behavior.
Choice B: Asking others on the team may provide additional insights but does not address the immediate need to ensure patient safety.
Choice D: Concluding that the coworker's fatigue is not her problem to solve neglects the responsibility to advocate for patient safety.
Overall, choice C is the most appropriate action to take in this situation to address the potential risk to patient care.
Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules; he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him b/c he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A because the child's inability to keep up with other kids in physical activities like running and jumping could indicate underlying physical or developmental issues that require further assessment and intervention. This could be a sign of motor skill delays, muscle weakness, or coordination problems that may impact the child's overall physical health and well-being. Options B, C, and D focus on behavioral, academic, and social issues which are important but not as urgent as addressing potential physical limitations that could affect the child's daily functioning and quality of life.
Nurse at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children?
- A. "childhood obesity"
- B. substance use disorders
- C. scoliosis screening
- D. front-seat seatbelt use
- E. stranger awareness
Correct Answer: A, B, C, E
Rationale: The correct topics for parents of school-age children are A, B, C, and E. A- Childhood obesity is relevant for promoting healthy habits. B- Substance use disorders prevention can educate parents on risks. C- Scoliosis screening is important for early detection. E- Stranger awareness is crucial for child safety. Choices D and any other options not selected are inappropriate as they do not directly relate to health promotion and primary prevention for school-age children.
Nursing instructor is reviewing which actions nurses can initiate w/o provider's prescription. Students should identify which of following as nurse-initiated? (Select all that apply.)
- A. Give morphine sulfate 1-2 mg IV every 1h as needed for pain
- B. Insert NG tube to relieve client's gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C, D, E
Rationale: Correct Answer: C, D, E
Rationale:
C: Showing a client how to use progressive muscle relaxation is an example of a nurse-initiated action as it involves client education and does not require a provider's prescription.
D: Performing a daily bath after the evening meal is a routine nursing care activity that can be initiated by the nurse without a provider's prescription.
E: Re-positioning a client every 2 hours to reduce the risk of pressure ulcers is an essential nursing intervention that can be initiated by the nurse without a provider's prescription.
Summary of Incorrect Choices:
A: Giving morphine sulfate IV every 1 hour as needed for pain requires a provider's prescription due to the administration of a controlled substance.
B: Inserting an NG tube to relieve gastric distension is an invasive procedure that typically requires a provider's order and specialized training.
When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place?
- A. Client able to discuss appropriate technique
- B. Client able to demonstrate appropriate technique
- C. Client states he understands
- D. Client is able to write steps on piece of paper
Correct Answer: B
Rationale: The correct answer is B because demonstrating the appropriate technique shows psychomotor learning has taken place. This means the client can physically perform the actions involved in drawing up and mixing insulin injections. Merely discussing the technique (choice A) or stating understanding (choice C) doesn't necessarily mean the client can apply the knowledge in practice. Writing steps on paper (choice D) assesses cognitive understanding, not physical skill. In summary, the ability to physically demonstrate the technique is a direct indicator of psychomotor learning, making choice B the best option.