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The nurse recognizes which of the following may be used as an approved client identifier? Select all that apply.
- A. first and last name
- B. date of birth
- C. telephone number
- D. admission date
- E. medical record number
- F. age
Correct Answer: A,B,E
Rationale: First and last name, date of birth, and medical record number are approved identifiers per Joint Commission standards. Telephone number, admission date, and age are not.
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The nurse is caring for a client immediately following scleral buckling surgery for a retinal detachment of the right eye. Which of the following actions would be appropriate for the nurse to take?
- A. Place the client in a prone position
- B. Approach the client from the left side
- C. Instruct the client to perform deep breathing and coughing exercises
- D. Instruct client to avoid bending down
- E. Orientate the client to the environment
- F. Obtain a prescription for a stool softener
Correct Answer: B,D,E,F
Rationale: Post-scleral buckling surgery, the client’s positioning depends on the surgeon’s orders, but prone positioning is often avoided to prevent pressure on the eye. Approaching from the left side preserves the client’s intact visual field. Deep breathing and coughing may increase intraocular pressure and are typically avoided. Avoiding bending down prevents increased intraocular pressure. Orienting the client to the environment promotes safety due to potential vision changes. A stool softener prevents straining, which could increase intraocular pressure.
The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 1 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
Select the three (3) client findings that require immediate follow-up for a 67-year-old female client with progressive multiple sclerosis.
- A. reports of fatigue
- B. heat sensitivity
- C. activity intolerance
- D. medication adherence
- E. ambulation assistance
- F. muscle incoordination
- G. characteristics of pain
Correct Answer: D,E,F
Rationale: Medication adherence (incomplete antibiotic course) risks recurrent cystitis, ambulation assistance (using furniture) indicates fall risk, and muscle incoordination increases injury risk, requiring immediate intervention.
The first bodily area to be washed during a complete bed bath is the:
- A. Inner canthus of the eye
- B. Cheeks
- C. Forehead
- D. Chin
Correct Answer: A
Rationale: Washing from the inner canthus of the eye outward prevents debris spread and is the starting point for a bed bath. Other areas follow.
Which of the following statements about security in healthcare environments is accurate?
- A. Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility.
- B. All members of the healthcare facility must have education and training relating to security in the facility.
- C. Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility.
- D. Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility.
Correct Answer: B
Rationale: All healthcare staff, regardless of role, require security training to ensure safety. Egress alarms are not universally required, and excluding non-clinical or clerical staff is incorrect.
The nurse is teaching a continuing education course on communicable diseases. Which of the following statements should the nurse make about diphtheria? Select all that apply.
- A. The organism that causes this condition is Corynebacterium diphtheriae.
- B. Vaccination is available starting at two months of age.
- C. Transmission of the cutaneous diphtheria is via direct contact with the infected person.
- D. Airborne precautions are required for individuals with pharyngeal diphtheria.
- E. Diphtheria is caused by a virus and is highly contagious.
Correct Answer: A,B,C,D
Rationale: Diphtheria is caused by Corynebacterium diphtheriae, vaccinated via DTaP at two months, cutaneous form spreads by contact, and pharyngeal diphtheria requires airborne precautions. It is bacterial, not viral.