Nokea
Vaccines provide what type of immunity?
- A. active
- B. passive
- C. transplacental
- D. active and passive
Correct Answer: A
Rationale: Vaccines stimulate the body's immune system to produce antibodies, conferring active immunity. Passive immunity involves transferred antibodies, and transplacental immunity is a form of passive immunity from mother to fetus.
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The nurse notices that a family is waiting at the nursing station desk for its loved one to be brought to the unit for admission during a change-of-shift report. The nurse should:
- A. request that the family wait for its loved one in the client's room and wait to resume the report until the family has left the desk area.
- B. request that a nursing assistant bring coffee for the family while it waits at the desk and continue with the report.
- C. request that the family have a seat in the station rather than stand while awaiting its loved one.
- D. request that the family wait for its loved one in the Emergency Department waiting room.
Correct Answer: A
Rationale: To protect the privacy of clients and the confidentiality of the information shared in a change-of-shift report, the family should be asked to wait in the client's room, and the report should be resumed only after it can no longer hear what is said.
Which of the following nursing actions is most effective when evaluating a kinetic family drawing?
- A. telling the child to draw their family doing something
- B. offering specific suggestions of what to include in the drawing
- C. discouraging the child from talking about the drawing
- D. noting the omission of any family members
Correct Answer: D
Rationale: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the client to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.
While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. The nurse should:
- A. make the charge nurse on the unit aware of the situation so that he or she can take the necessary steps to maintain the confidentiality of the information being reported.
- B. disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
- C. return to his or her own unit and not disclose that confidential information has been overheard.
- D. ignore the situation.
Correct Answer: A
Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation so that the information can be communicated in an appropriate way in privacy.
The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following would be least appropriate?
- A. Begin client data collection prior to receiving the physician's order for the referral.
- B. Use documents to contribute information for the referral.
- C. Wait for the physician to order speech therapy and then assist with the appropriate documentation.
- D. Participate in the client referral process.
Correct Answer: C
Rationale: The nurse should participate in the client referral process, collect client data, and use appropriate documents to contribute information. It is not necessary to wait for the physician's order if the nurse recognizes the need for client referral.
Which of the following is not true of clinical pathways?
- A. They need to be updated daily.
- B. They show how the client is expected to respond to their diagnosis.
- C. The goal is improvement or discharge from the facility.
- D. They are evidence based.
Correct Answer: A
Rationale: Clinical pathways may be daily or weekly, so they may not need to be updated every day.