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A home health nurse is discussing the dangers of food poisoning w/a client. Which of the following info should the nurse include in her counseling? Select all.
- A. Most food poisoning is caused by a virus
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are especially at risk are instructed to eat or drink only pasteurized milk, yogurt, cheese, or other dairy products
- D. Healthy individuals usually recover from the illness in a few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B, C, E
Rationale: The correct choices are B, C, and E. B is correct because immunocompromised individuals have weakened immune systems, making them more susceptible to severe complications from food poisoning. C is correct because pasteurized dairy products are less likely to contain harmful bacteria that can cause food poisoning. E is correct because proper food handling, such as separating raw and fresh foods to prevent cross-contamination, can help reduce the risk of food poisoning. A is incorrect because most food poisoning is actually caused by bacteria, not viruses. D is incorrect because while healthy individuals may recover from food poisoning, the recovery time can vary and may not always be within a few weeks.
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A nurse is instructing an AP in caring for a client who has a low platelet count as a result of chemotherapy. Which of the following is the nurse's priority instruction for measuring vital signs for this client?
- A. Don't measure the client's temperature rectally.'
- B. Count the client's radial pulse for 30 seconds & multiply by 2.'
- C. Don't let the client know you are counting her respirations.'
- D. Let the client rest for 5 minutes before you measure her BP.'
Correct Answer: A
Rationale: Correct Answer: A: Don't measure the client's temperature rectally.
Rationale: Clients with low platelet count are at risk for bleeding. Rectal temperature measurement poses a risk of mucosal injury and bleeding due to the fragility of the rectal mucosa. Therefore, the nurse's priority instruction is to avoid rectal temperature measurement to prevent any potential harm to the client.
Summary:
B: Counting the radial pulse for 30 seconds and multiplying by 2 is a valid method for measuring heart rate but is not the priority instruction in this case.
C: It is important for the client to be aware that respirations are being counted to ensure accurate measurement. However, this is not the priority instruction for vital sign measurement.
D: Allowing the client to rest for 5 minutes before measuring blood pressure is a good practice, but it is not the priority instruction compared to avoiding rectal temperature measurement for a client with low platelet count.
A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all.
- A. I will observe for med side effects.
- B. I will monitor for therapeutic effects.
- C. I will prescribe the appropriate dose.
- D. I will change the dose if adverse effects occur.
- E. I will refuse to give a med if I believe it is unsafe.
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A nurse's responsibility in implementing medication therapy includes observing for side effects (A), monitoring for therapeutic effects (B), and refusing to give a medication if they believe it is unsafe (E).
A - Observing for side effects is crucial in ensuring patient safety and prompt intervention if adverse reactions occur.
B - Monitoring for therapeutic effects helps assess the effectiveness of the medication in achieving the desired outcomes for the patient's condition.
E - Refusing to give a medication if the nurse believes it is unsafe demonstrates advocacy for the patient's well-being and adherence to the principles of safe medication administration.
Choices C and D are incorrect because nurses should not prescribe or change medication doses without proper authorization from a prescribing healthcare provider. It is beyond the scope of a nurse's role.
In summary, the correct answers focus on patient safety, monitoring effectiveness, and advocating for the patient's best interest, while the incorrect choices involve actions outside the nurse's scope
A nurse prepares to administer an injection of morphine (Duramorph) to a client who reports pain. Prior to administering, the nurse is called to another room to assist another client onto a bedpan. She asks a 2nd nurse to give the injection. Which of the following actions should the 2nd nurse take?
- A. Offer to assist the client needing the bedpan.
- B. Administer the injection prepared by the other nurse.
- C. Prepare another syringe & administer the injection.
- D. Tell the client needing the bedpan she will have to wait for her nurse.
Correct Answer: A
Rationale: The correct answer is A. The second nurse should offer to assist the client needing the bedpan. This is important for patient safety and continuity of care. By offering assistance, the second nurse ensures that the immediate needs of the client are met promptly. Administering the injection prepared by the other nurse (B) may lead to errors and violates the principle of accountability. Preparing another syringe and administering the injection (C) is unnecessary and could delay care for the client needing assistance. Telling the client needing the bedpan to wait (D) is not appropriate as it neglects the client's needs.
To promote the safe use of a cane for a client who is recovering from a minor musculoskeletal injury of the left lower extremity, which of the following instructions should the nurse provide? Select all.
- A. Hold the cane on the right side
- B. Keep 2 points of support on the floor
- C. Place the cane 15 inches in front of the feet before advancing
- D. After advancing the cane, move the weaker leg forward
- E. Advance the stronger leg so that it aligns evenly with the cane
Correct Answer: A, B, D
Rationale: Correct Answer: A, B, D
Rationale:
A: Holding the cane on the right side provides support for the weaker left lower extremity, aiding balance.
B: Keeping 2 points of support on the floor enhances stability and reduces the risk of falls.
D: Moving the weaker leg forward after advancing the cane promotes weight-bearing on the stronger leg first, reducing strain on the injured limb.
Summary:
C: Placing the cane 15 inches in front of the feet before advancing is too far and may lead to overreaching.
E: Advancing the stronger leg to align with the cane may shift the body weight incorrectly, increasing the risk of injury.
A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?
- A. Encourage isometric exercises
- B. Suction Q8 hr
- C. Give low-dose heparin
- D. Promote incentive spirometer use
Correct Answer: D
Rationale: The correct answer is D: Promote incentive spirometer use. This intervention helps prevent atelectasis, a common complication of prolonged bed rest. Using the incentive spirometer helps the client take deep breaths and improve lung function, thereby maintaining airway patency. Encouraging isometric exercises (choice A) does not specifically target airway patency. Suctioning every 8 hours (choice B) is not necessary unless there is a specific indication. Giving low-dose heparin (choice C) is used to prevent blood clots, not to maintain airway patency.