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The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right
- A. intention
- B. alternative
- C. assessment
- D. task
Correct Answer: D
Rationale: The five rights of delegation include the right task, ensuring appropriate delegation.
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The nurse is teaching a group of students about incident reports. Which of the following statements made by the student would require further teaching?
- A. Reporting can only be completed if it is within one hour after the event.
- B. Witnesses to an incident should be mentioned in the report.
- C. A client eloping does not require an incident report.
- D. A slip and fall by a client should be reported.
- E. Incidents involving visitors do not have to be reported.
Correct Answer: A, C, E
Rationale: Incident reports can be filed anytime, elopement requires reporting, and visitor incidents should be reported.
The nurse assists a client with cystic fibrosis in picking out items on a menu. It will indicate effective teaching if the client selects meals that are
- A. high in fat
- B. low in sodium
- C. low in calories
- D. low in protein
Correct Answer: A
Rationale: High-fat meals provide necessary calories for cystic fibrosis patients with high energy needs.
The nurse is educating a group of students on the measles, mumps, and rubella (MMR) vaccine. Which statement, if made by the student, would indicate effective teaching?
- A. Egg allergy is a contraindication to giving this vaccine.
- B. This is a three-series vaccine that should be started at birth.
- C. It is safe for breastfeeding women to receive the MMR vaccine.
- D. This vaccine is safe if the client is pregnant.
Correct Answer: C
Rationale: The MMR vaccine is safe for breastfeeding women but contraindicated in pregnancy and not started at birth. Egg allergy is no longer a contraindication.
The nurse is caring for a client seven hours postoperative following a subtotal thyroidectomy. The client reports peripheral numbness and tingling, muscle twitching, and spasms. The nurse anticipates a prescription for
- A. levothyroxine
- B. hydrocortisone
- C. thiamine
- D. calcium gluconate
Correct Answer: D
Rationale: These symptoms suggest hypocalcemia, a common complication post-thyroidectomy due to parathyroid gland disruption. Calcium gluconate is the appropriate treatment.
The following scenario applies to the next 6 items
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
Item 1 of 6
Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Which of the following assessment findings require immediate follow-up?
- A. lung sounds
- B. pupil assessment
- C. abdominal assessment findings
- D. pulse, respirations, and blood pressure
- E. Glasgow coma scale
- F. speech characteristics
- G. home medications
Correct Answer: B, E, G
Rationale: Pupil sluggishness, Glasgow Coma Scale of 14, and warfarin use (increasing bleeding risk) require immediate follow-up due to potential traumatic brain injury.