Nokea
A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP?
- A. Feeding client who was admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching w/ client who is learning to walk using quad cane
- C. Reapplying a condom catheter for client who has urinary incontinence
- D. Applying sterile dressing to pressure ulcer
Correct Answer: C
Rationale: The correct answer is C. The nurse can assign the task of reapplying a condom catheter for a client with urinary incontinence to an unlicensed assistive personnel (AP) because it is a routine, non-invasive procedure that does not require specialized nursing skills. The AP can be trained to perform this task safely under the nurse's supervision.
A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse.
B: Teaching a client to walk using a quad cane involves assessing the client's safety and gait, which should be done by a licensed nurse.
D: Applying a sterile dressing to a pressure ulcer requires knowledge of wound care principles and infection control, which should be done by a licensed nurse.
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Nurse wearing sterile gloves in preparation for performing a sterile procedure. Which of the following objects may the nurse touch without breaching sterile technique? (Select all that apply.)
- A. Bottle containing sterile solution
- B. Edge of sterile drape at base of field
- C. Inner wrapping of an item on sterile field
- D. Irrigation syringe on sterile field
- E. One gloved hand with the other gloved hand
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: The nurse can touch the inner wrapping of an item on the sterile field because it is considered part of the sterile field and does not compromise the sterility.
D: The nurse can touch the irrigation syringe on the sterile field as it is within the sterile field and maintaining sterility.
E: The nurse can touch one gloved hand with the other gloved hand as long as both hands are sterile.
Summary:
A: Incorrect - Nurse should not touch a bottle containing sterile solution as it is not part of the sterile field.
B: Incorrect - Nurse should avoid touching the edge of a sterile drape at the base of the field as it is considered unsterile.
F & G: Not applicable.
Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client?
- A. "suggest his parents room in with him"
- B. provide a TV & DVDs for him to watch
- C. limit visitors to immediate family
- D. devise a regular schedule for inpatient routines
- E. allow him to perform his own morning care
Correct Answer: B, E
Rationale: Correct Answer: B, E
Rationale:
B: Providing entertainment like TV and DVDs can help distract the adolescent from pain and boredom during recovery.
E: Allowing the adolescent to perform his own morning care promotes independence and self-esteem, aiding in his emotional well-being.
Summary:
A: Suggesting parents room in may not always be feasible or preferred by the adolescent.
C: Limiting visitors to immediate family can be isolating and may not address the adolescent's social needs.
D: While having a regular schedule is important, it may not address the adolescent's individual preferences and needs.
Nurse tells client that she will call surgeon & ask about his request. Surgeon hears nurse's report & prescribes full liquid diet. Nurse used which of following levels of critical thinking?
- A. basic
- B. commitment
- C. complex
- D. integrity
Correct Answer: A
Rationale: The correct answer is A: basic. In this scenario, the nurse is simply relaying information and following a routine procedure by contacting the surgeon for a prescription. This level of critical thinking involves basic understanding and application of knowledge without deeper analysis or evaluation. The other choices are incorrect because: B: commitment involves making decisions and taking responsibility; C: complex involves analyzing and evaluating information; D: integrity involves ethical decision-making. In this case, the nurse's action aligns with basic thinking as she is following a standard protocol without engaging in higher-level critical thinking processes.
Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information such as location, type of environment, and potential threats. By gathering this information discreetly, security personnel can better assess the situation and coordinate an appropriate response.
Choice A is incorrect because abruptly ending the call can hinder the ability to gather vital details. Choice B is incorrect as using overhead paging may cause panic and compromise safety. Choice C is incorrect because not asking questions can lead to missing important information.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.