Nokea
The nurse is planning an educational session for a group of parents with toddlers. Based on the two leading causes of death in toddlers, the nurse should make which topics priority? Select all that apply.
- A. Water safety and methods to prevent drowning.
- B. Use of age- and weight-appropriate car seats.
- C. Nutrition guidelines and age-appropriate foods.
- D. Use of labels to identify poisonous substances.
- E. Safety when outdoors and crossing the street.
Correct Answer: A,B
Rationale: Drowning and motor vehicle accidents are the top two causes of death in toddlers, making water safety and car seat use priority topics.
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The charge nurse is observing nursing staff. In which activity illustrated should the charge nurse intervene because it places the nurse most at risk for back injury?
- A. intervene_1.PNG
- B. intervene_2.PNG
- C. intervene_3.PNG
- D. intervene_4.PNG
Correct Answer: D
Rationale: Bending and twisting the torso, as described in option D, poses the highest risk for back injury due to improper body mechanics, even with a transfer belt. The client's potential to grab the nurse's shoulder or arm increases the risk by destabilizing the nurse's stance.
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
- A. Place client in the wheelchair for four hours each day
- B. Pad the bony prominence
- C. Reposition every two hours
- D. Massage reddened bony prominence
Correct Answer: C
Rationale: Reposition every two hours. Clients who are at risk for skin breakdown develop fewer pressure ulcers when turned every two hours. By relieving the pressure over bony prominences at frequent scheduled intervals, blood flow to areas of potential injury is maintained.
Hearing screening of prematurely born infants is an effective means of identifying disease and is an example of:
- A. primary prevention.
- B. secondary prevention.
- C. tertiary prevention.
- D. disability prevention.
Correct Answer: B
Rationale: The three levels of prevention address disease and disability across all phases, from absence of disease and at risk for disease, to preventing further impairment. Hearing impairment associated with prematurity cannot be prevented by screening, but identifying the infants with hearing loss might prevent sequelae and further impairment by allowing early intervention.
Serum Vancomycin levels are taken to measure which of the following?
- A. renal function
- B. therapeutic range
- C. trough levels
- D. antibiotic resistance
Correct Answer: B
Rationale: Vancomycin levels are monitored to ensure therapeutic effects by peak level.
The home health nurse is using the home Safety Assessment Scale to evaluate the dangers that may exist in the home of the client who is mildly cognitively impaired. Which finding on the scale should be most concerning to the nurse?
- A. Lives alone and has no spouse or living children
- B. Places cloth items on stove when burners are on
- C. Is unable to recognize when food is spoiled
- D. Has poor vision and doesn't wear glasses
Correct Answer: B
Rationale: Placing cloth items on a hot stove poses an immediate fire risk, which is the most concerning safety hazard for a cognitively impaired client.