Nokea
The partner tells the nurse that she is able to manage the client’s physical care but she doesn’t want to leave him home alone while she travels for work. Which of the following referrals should the nurse make?
- A. Respite care
- B. Promoting healthy lifestyle behavior choices among the community members
- C. Eliciting the health history of a client presenting with an illness
- D. Establishing screening programs to diagnosis diseases as early as possible
Correct Answer: A
Rationale: The correct answer is A: Respite care. Respite care provides temporary relief to the primary caregiver by offering a safe environment for the client while the partner is away. This ensures the client's well-being and safety in the partner's absence. Other choices are incorrect because B focuses on community health, C involves health history assessment, and D pertains to screening programs which are not relevant to the partner's immediate concern of leaving the client home alone.
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Which statement describes the actions of a nurse who follows Nightingale's Environmental Theory?
- A. Identifying strategies to reduce climate change
- B. Encouraging the use of public transportation
- C. Promoting environmental justice for all people
- D. Using the client's environment to assist in recovery
Correct Answer: D
Rationale: The correct answer is D because Nightingale's Environmental Theory emphasizes the importance of the environment in promoting health and recovery. By using the client's environment to assist in recovery, the nurse is applying Nightingale's principles of creating a healing environment. Choices A, B, and C focus on broader environmental issues, which are important but not directly related to Nightingale's theory of nursing. The nurse's primary focus should be on utilizing the immediate environment to support the client's healing process.
A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
- A. I can visit my nephew who has chickenpox 5 days after the sores have crusted.
- B. I should take antibiotics when I have a virus.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wash my hands for 10 seconds with hot water after working in the garden.
Correct Answer: A
Rationale: The correct answer is A: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." This statement indicates understanding of infection prevention as chickenpox is contagious until the sores crust over, which typically takes about 5 days. Visiting after this period reduces the risk of transmission. Choice B is incorrect because antibiotics are ineffective against viruses. Choice C is incorrect because pregnant individuals should avoid cleaning cat litter due to the risk of toxoplasmosis. Choice D is incorrect as handwashing should last at least 20 seconds with soap and warm water for effective prevention of infection.
A school health nurse plans to use evidence-based practice (EBP) to guide the development of health education programs most likely to increase retention of learning in elementary schoolchildren. Which of the following would be the best way to use EBP in this situation?
- A. Ask other school health nurses what they included in their own education programs.
- B. Compare and contrast randomized controlled trials related to learning in elementary schoolchildren.
- C. Develop a series of games to accompany the programs developed to promote health.
- D. Seek out and examine health education programs for elementary schoolchildren on the Internet.
Correct Answer: B
Rationale: The correct answer is B because comparing and contrasting randomized controlled trials related to learning in elementary schoolchildren is the best way to use evidence-based practice (EBP). This method involves systematically reviewing existing research studies to determine the most effective health education programs. Randomized controlled trials are considered the gold standard in research, providing the highest level of evidence. By analyzing these trials, the nurse can identify interventions that have been proven to be successful in increasing retention of learning in elementary schoolchildren.
Choice A is incorrect because relying solely on anecdotal evidence from other school health nurses does not constitute evidence-based practice. Choice C is incorrect as developing games may be a creative approach, but it does not ensure the effectiveness of the health education programs. Choice D is also incorrect as the internet may not always provide reliable or evidence-based information.
A nurse on a medical surgical unit is performing medication reconciliation for a newly admitted client. Which of the following actions should the nurse take?
- A. Compare the client's list of home medications to the admission prescriptions written for the client
- B. Working with community groups to create policies to improve the environment
- C. Recognizing the reasons why 30 minutes of walking each day is one of the best health promotion activities
- D. Asking community leaders what interventions should be chosen
Correct Answer: A
Rationale: The correct answer is A because medication reconciliation involves comparing the client's list of home medications with the admission prescriptions to ensure accuracy and prevent medication errors. This step is crucial in identifying any discrepancies or omissions in the client's medication regimen. Choice B is incorrect as it pertains to community policy development, unrelated to medication reconciliation. Choice C is incorrect as it focuses on health promotion activities, not medication reconciliation. Choice D is incorrect as it involves seeking community leaders' input, not relevant to medication reconciliation.
A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following actions by the newly-licensed nurse requires intervention by the staff nurse?
- A. Waits for 2 minutes between suctions
- B. Engaging in policy development and encourage and assist persons to communicate their needs
- C. Giving a very informative and engaging presentation
- D. Identifying and planning for high-risk populations
Correct Answer: A
Rationale: The correct answer is A because waiting for 2 minutes between suctions is not recommended practice for tracheostomy care. Suctioning should be performed as needed based on the patient's clinical presentation, not on a fixed time interval. Waiting too long between suctions can lead to ineffective removal of secretions, compromising the patient's airway.
Choice B, C, and D are incorrect because they are unrelated to the scenario of suctioning a tracheostomy. Choice B refers to policy development and communication skills, Choice C mentions giving a presentation, and Choice D involves planning for high-risk populations. These choices do not pertain to the immediate nursing intervention needed during tracheostomy care.