Nokea
The PN observes a UAP bathing a bedfast client with the bed in the high position. Which action should the PN take?
- A. Remain in the room to supervise the UAP
- B. Determine if the UAP would like assistance
- C. Assume care of the client immediately
- D. Instruct the UAP to lower the bed for safety
Correct Answer: D
Rationale: The correct action for the PN to take in this situation is to instruct the UAP to lower the bed for safety. Keeping the bed in the lowest position during care activities is crucial for preventing falls and injuries to both the client and the caregiver. Instructing the UAP to lower the bed addresses the immediate safety concern. Choice A is incorrect because simply supervising the UAP without addressing the unsafe bed height does not ensure the client's safety. Choice B is incorrect as the priority is to address the safety concern rather than offering assistance to the UAP. Choice C is incorrect as assuming care of the client immediately does not address the root issue of the high bed position.
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During a fire incident in a long-term care facility's kitchen, which task is most crucial for the PN to perform instead of delegating to UAP?
- A. Close the doors to all residents' rooms
- B. Offer comfort and reassurance to each resident
- C. Identify the method for transporting and evacuating each resident
- D. Provide blankets to each resident for use during evacuation
Correct Answer: C
Rationale: During a fire emergency, the most critical task for the PN is to identify the method for transporting and evacuating each resident. This task ensures a safe and organized evacuation plan, which is essential for everyone's safety. Delegating this responsibility to an unlicensed assistive personnel (UAP) may lead to errors or delays in the evacuation process. Closing doors to residents' rooms (Choice A) can help contain the fire but is not as urgent as planning the evacuation. While offering comfort and reassurance (Choice B) is important, it should not take precedence over ensuring a safe evacuation. Providing blankets (Choice D) is helpful but does not directly address the primary concern of safely evacuating residents.
You have a patient who has just had a diagnostic arthroscopy. You are instructing him about what to do when he gets home. Which of the following would you NOT instruct him to do?
- A. Resume normal activities within 12 hours so as to help reduce the swelling
- B. Elevate the extremity for 24 - 48 hours
- C. Apply ice to the area involved intermittently
- D. Report severe pain to the physician immediately
Correct Answer: A
Rationale: Patients should rest and avoid normal activities for a short period after arthroscopy to allow healing and prevent swelling, which could worsen with early activity. Elevation and icing are recommended post-procedure to reduce swelling and pain. Instructing the patient to resume normal activities within 12 hours could lead to increased swelling and delayed healing. Reporting severe pain is crucial as it could indicate a complication. Therefore, the correct instruction is not to resume normal activities immediately after arthroscopy.
An 8-year-old is placed in 90-90 traction for a fractured femur resulting from a motor vehicle collision. Which finding requires further action by the PN?
- A. No bowel movement for two days
- B. Mother assists child in changing positions
- C. Weights are touching the foot of the bed
- D. Child is able to move the toes freely when tickled
Correct Answer: C
Rationale: In 90-90 traction, it is crucial to ensure that the weights are not touching the foot of the bed as this can disrupt the effective application of traction. This interference can hinder the proper alignment of the fractured femur and impede the healing process. Therefore, this finding requires immediate action to prevent complications. Choices A, B, and D are not directly related to the proper application of traction and do not pose a risk to the patient's treatment or well-being. No bowel movement for two days may indicate constipation but does not directly relate to the traction. Mother assisting the child in changing positions is a supportive action. The child being able to move the toes freely when tickled indicates neurological function, which is a positive sign.
When assisting an older male client recovering from a stroke to ambulate with a cane, where should the nurse place the cane in relation to the client's body?
- A. In front of the body to lean on while stepping forward
- B. On the opposite side of the affected extremity
- C. Approximately one foot away from the body to stabilize balance
- D. On the same side as the affected extremity
Correct Answer: B
Rationale: The correct answer is B: 'On the opposite side of the affected extremity.' Placing the cane on the opposite side of the affected extremity provides maximum support and stability during ambulation for a client recovering from a stroke. This positioning helps to offload weight from the affected side and improves balance. Choice A is incorrect because placing the cane in front of the body can lead to incorrect weight distribution and instability. Choice C is incorrect as placing the cane one foot away from the body may not provide adequate support and can compromise balance. Choice D is incorrect as placing the cane on the same side as the affected extremity does not offer the necessary balance and support needed for safe ambulation.
What is the primary role of the sinoatrial (SA) node in the heart?
- A. Pacemaker of the heart
- B. Blood pressure regulation
- C. Electrical conduction delay
- D. Stimulating muscle contraction
Correct Answer: A
Rationale: The correct answer is A: Pacemaker of the heart. The SA node, known as the natural pacemaker, initiates the electrical impulses that set the rhythm for the heartbeat. It is responsible for coordinating the heart's contractions by generating electrical signals at regular intervals. Choice B is incorrect as the SA node's primary function is not related to blood pressure regulation. Choice C is incorrect as the SA node does not cause electrical conduction delay but rather initiates and conducts the electrical impulses. Choice D is incorrect as the SA node does not directly stimulate muscle contraction but rather initiates the electrical events that lead to muscle contraction.