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The patient has been in bed for several days and needs to be ambulated. Which action will the nurse take first?
- A. Maintain a narrow base of support.
- B. Encourage the patient to dangle at the bedside.
- C. Encourage isometric exercises at the bedside.
- D. Suggest a high-calcium diet.
Correct Answer: B
Rationale: The correct answer is B: Encourage the patient to dangle at the bedside. This is the first step in ambulating a patient who has been in bed for several days. Dangling helps prevent postural hypotension by allowing the patient's body to adjust gradually to an upright position. Maintaining a narrow base of support (A) is important during ambulation but comes after dangling. Isometric exercises (C) and suggesting a high-calcium diet (D) are not immediate actions needed for ambulation.
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A nurse is receiving a provider prescription by phone for morphine for a client who is reporting moderate to severe pain. Which of the following actions are appropriate?
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber's signature within 24 hours
- D. Decline verbal prescription because it is not an emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A,B,C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details of the prescription back to the provider ensures accuracy and reduces errors in transcription.
B: Having another nurse listen to the phone prescription provides a second verification to ensure accuracy and compliance with protocols.
C: Obtaining the prescriber's signature within 24 hours is necessary for legal documentation and accountability.
Summary:
Option D is incorrect because declining a verbal prescription in a non-emergency situation could delay necessary pain relief for the client. Option E is irrelevant to the immediate task of correctly processing the prescription.
A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal calculi
- C. Pressure ulcers
- D. Thrombus formation
Correct Answer: B
Rationale: The correct answer is B: Renal calculi. Hypercalcemia can lead to the formation of kidney stones (renal calculi) due to increased levels of calcium in the blood being excreted by the kidneys. The nurse should monitor for signs and symptoms of renal colic, such as severe flank pain, hematuria, and urinary urgency.
Incorrect choices:
A: Hypostatic pneumonia - Hypercalcemia does not directly lead to pneumonia.
C: Pressure ulcers - Hypercalcemia does not increase the risk of pressure ulcers.
D: Thrombus formation - While hypercalcemia can predispose to blood clot formation, it is not the most closely monitored condition in this scenario.
Nurse reviewing carseat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include?
- A. Use car seat that has 3-point harness
- B. Position car seat so that infant is rear-facing
- C. Secure car seat in front passenger seat of car
- D. Put soft padding in car seat behind infants back & neck
Correct Answer: B
Rationale: The correct answer is B: Position car seat so that infant is rear-facing. This is important because rear-facing car seats are known to provide the best protection for infants in the event of a crash, as they support the head, neck, and spine. Other choices are incorrect because: A: A 3-point harness may not provide sufficient support for an infant's small body. C: Placing the car seat in the front passenger seat can be dangerous due to the presence of airbags. D: Soft padding can be a suffocation hazard and interfere with the proper fit of the harness.
Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A) Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C) Turning pot handles toward the back of the stove prevents toddlers from accidentally pulling them down. D) Placing safety gates across stairways prevents toddlers from falling down stairs. B) Keeping toilet seats up increases the risk of toddlers falling in. E) Having balloons fully inflated poses a choking hazard. In summary, choices A, C, and D are important strategies for accident prevention, while choices B and E can actually increase risks for toddlers.
Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.)
- A. HPV
- B. Measles, mumps, rubella
- C. Varicella
- D. Haemophilus influenzae type b
- E. Polio
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. The nurse should include HPV, measles, mumps, rubella, and varicella in the discussion as these are recommended immunizations for young adults by the CDC. HPV vaccination helps prevent certain types of cancers and genital warts. Measles, mumps, and rubella vaccines protect against highly contagious diseases. Varicella vaccine prevents chickenpox. Choices D, E, F, and G are incorrect. Haemophilus influenzae type b and polio vaccines are typically given during infancy and childhood, not young adulthood. The options F and G are incomplete.