Nurse talking with parents of 6 mo infant about gross motor...

Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.)

A. Rolls from back to front
B. Bears weight on legs
C. Walks holding onto furniture
D. Sits unsupported
E. Sits down from standing position

Correct Answer: A,B,D

Rationale: The correct answer is A, B, and D. By 9 months, infants typically develop the ability to roll from back to front (choice A), bear weight on legs (choice B), and sit unsupported (choice D). Rolling from back to front demonstrates improved core strength and coordination. Bearing weight on legs indicates developing leg muscles and balance. Sitting unsupported signifies improved trunk control and balance. Choices C and E involve more advanced skills typically seen around 9-12 months. Choice C, walking holding onto furniture, is usually seen around 10-12 months, and choice E, sitting down from a standing position, typically emerges around 9-12 months.

Nurse caring for 19 yo client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?

A. Measure the vital signs
B. Encourage HIV screening
C. Determine client's risk factors
D. Instruct client to use condoms

Correct Answer: C

Rationale: The correct answer is C: Determine client's risk factors. This intervention is essential to assess the client's current health status, identify potential health risks, and develop a personalized health promotion plan. By understanding the client's risk factors, the nurse can provide targeted education and interventions to prevent diseases and promote overall well-being.

A: Measuring vital signs is important but does not directly address health promotion and disease prevention specific to the client's sexual activity.
B: Encouraging HIV screening is important, but it focuses on a specific disease rather than a comprehensive assessment of risk factors.
D: Instructing the client to use condoms is important for safe sex practices but does not address broader health promotion and disease prevention strategies effectively.

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.

Mother of 7 mo infant tells nurse that her baby has been fussy with occasional loose stools since she started feeding him fruits & veggies. Which responses by nurse are appropriate? (Select all that apply.)

A. It might be good to add bananas, as they help with loose stools
B. Let's make list of foods he's eating so we can spot problems
C. Did the changes begin after you started 1 particular food?
D. Has he been vomiting since he started these new foods?
E. Most babies react with indigestion when you start new foods

Correct Answer: B,C,D

Rationale: Correct Answer: B, C, D

Rationale:
B: Making a list of foods eaten helps identify potential triggers causing the baby's symptoms.
C: Asking about specific foods helps pinpoint if a particular food is causing the issues.
D: Inquiring about vomiting helps assess if the baby's symptoms could be due to a more serious underlying issue.

Incorrect Choices:
A: Bananas may not necessarily help with loose stools, and adding new foods without identifying the problem isn't ideal.
E: Not all babies react with indigestion to new foods, making this statement too general and not helpful in this case.

RN is making assignments for client care to LPN at beginning of shift. Which of following assignments should LPN question?

A. Assisting a client who is 24h post-op to use incentive spirometer
B. Collecting clean-catch urine specimen from client who was admitted on previous shift
C. Providing nasopharyngeal suctioning for client with pneumonia
D. Replacing cartridge & tubing on PCA pump

Correct Answer: D

Rationale: The correct answer is D: Replacing cartridge & tubing on PCA pump. This is the assignment the LPN should question. The rationale is that LPNs are not typically trained to handle complex medical devices like PCA pumps, which deliver controlled doses of pain medication. LPNs should question this task as it involves intricate technical skills and potential risks if done incorrectly.

A: Assisting a client with an incentive spirometer is within an LPN's scope of practice and does not require specialized training.
B: Collecting a clean-catch urine specimen is a routine task that LPNs are typically trained to perform.
C: Providing nasopharyngeal suctioning for a client with pneumonia is a common nursing intervention that LPNs are qualified to carry out.

In summary, LPNs should question assignments that are outside their scope of practice or involve technical procedures beyond their training to ensure safe and effective care for the clients.

Nurse is reviewing hand hygiene techniques with a group of APs. Which instructions should the nurse include when discussing handwashing? (Select all that apply.)

A. Apply 3-5 mL of liquid soap to dry hands
B. Wash hands with soap & water for at least 15 seconds
C. Rinse hands with hot water
D. Use a clean paper towel to turn off hand faucets
E. Allow hands to air dry after washing

Correct Answer: B,D

Rationale: Correct Answer: B, D

Rationale:
B: Washing hands with soap & water for at least 15 seconds is crucial to ensure thorough cleaning and removal of germs.
D: Using a clean paper towel to turn off hand faucets helps prevent recontamination of clean hands.

Incorrect Choices:
A: Applying 3-5 mL of liquid soap to dry hands is not specified in handwashing guidelines.
C: Rinsing hands with hot water can strip the skin of natural oils and may not be necessary for effective hand hygiene.
E: Allowing hands to air dry after washing may not be sufficient to eliminate germs and is not a recommended step in hand hygiene protocols.