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Nurse receives prescription for antibiotic for client with cellulitis. Nurse checks client's med record, discovers she's allergic to it, & calls provider to request different one. Which of following attitudes did the nurse demonstrate?
- A. fairness
- B. responsibility
- C. risk taking
- D. creativity
Correct Answer: B
Rationale: The correct answer is B: responsibility. The nurse demonstrated responsibility by ensuring patient safety and advocating for a suitable alternative antibiotic after discovering the allergy. This action aligns with the nurse's duty to provide safe and effective care.
Other choices are incorrect:
A: Fairness doesn't apply as the nurse's action was based on patient safety, not fairness.
C: Risk-taking is not demonstrated; the nurse acted based on known risks of the allergic reaction.
D: Creativity is not applicable here; the nurse followed standard protocols for managing allergies.
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Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion?
- A. "rotavirus"
- B. varicella
- C. herpes zoster
- D. HPV
- E. seasonal influenza
Correct Answer: B, D, E
Rationale: The correct answers are B (varicella), D (HPV), and E (seasonal influenza) because these are recommended immunizations for adolescents by the CDC. Varicella vaccine protects against chickenpox, HPV vaccine prevents certain types of cancers, and seasonal influenza vaccine helps prevent the flu. Rotavirus (A) is typically given to infants, not adolescents. Herpes zoster (C) is recommended for older adults, not adolescents.
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.
Nurse observes smoke coming from under door of staff lounge. Which is priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The priority action for the nurse in this scenario is to evacuate the clients (Choice C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (Choice B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (Choice A) may put the nurse at risk and delay client evacuation. Closing doors (Choice D) may contain the fire but does not address the immediate need of client safety.
Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Removing the crib gym is crucial as it can pose a choking hazard. Infants should sleep on a firm mattress to reduce the risk of suffocation, making option B incorrect. Option C is unsafe as soft pillows increase the risk of suffocation. Option D, while mentioning a safety gate, doesn't directly address infant safety.
Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: Correct Answer: A, B, D
Rationale:
A: Requesting assistance when repositioning a client is crucial to prevent injury as it reduces the risk of strain on the nurse's body.
B: Avoiding twisting the spine or bending at the waist helps in maintaining proper body mechanics and prevents back injuries.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Summary of Incorrect Choices:
C: Keeping knees slightly lower than hips when sitting for long periods is related to ergonomics but not directly to preventing injury with client handling.
E: Taking breaks from repetitive movements every 2-3 hours is important for overall health but not specific to preventing injury with client handling.