Nokea
What does client and family communication and education concerning restraints do?
- A. confuses both groups more
- B. helps with coping and stress levels
- C. encourages cooperation with the client and family
- D. puts the responsibility on the client and family, not the nurse
Correct Answer: C
Rationale: Cooperation is more likely if the client and family understand the purpose of and expected gains from restraints. Well-meaning family members might release restraints if their purpose is not clear.
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The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source of fluids for an infant until about 12 months of age?
- A. Formula or breast milk
- B. Dilute nonfat dry milk
- C. Warmed fruit juice
- D. Fluoridated tap water
Correct Answer: A
Rationale: Formula or breast milk. Formula or breast milk are the perfect food and source of nutrients and liquids up to 1 year of age.
The nurse is planning an educational session for a group of parents with toddlers. Based on the two leading causes of death in toddlers, the nurse should make which topics priority? Select all that apply.
- A. Water safety and methods to prevent drowning.
- B. Use of age- and weight-appropriate car seats.
- C. Nutrition guidelines and age-appropriate foods.
- D. Use of labels to identify poisonous substances.
- E. Safety when outdoors and crossing the street.
Correct Answer: A,B
Rationale: Drowning and motor vehicle accidents are the top two causes of death in toddlers, making water safety and car seat use priority topics.
How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
- A. 1 foot
- B. 2 feet
- C. 4 feet
- D. 6 feet
Correct Answer: D
Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger.
A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?
- A. To observe the type and amount of nasogastric tube drainage
- B. Monitor the client for nausea or other complications
- C. Irrigate the nasogastric tube with the ordered irrigant
- D. Perform nostril and mouth care
Correct Answer: D
Rationale: Skin care around a nasogastric tube is a routine task that is appropriate for UAPs. The other tasks involve assessment or advanced skills that require a licensed nurse.
Prior to checking a fingerstick blood glucose level, the nurse checks the identification band of the newly admitted client transferred from another facility. The nurse notes that the name and birth date are correct but that the band has the logo from another facility. Which is the best action by the nurse?
- A. Ask the UAP to obtain a new band while the nurse performs the planned procedure.
- B. Stop and replace the band with the current facility band that has the client identifiers.
- C. Ask the client to state his or her name and birth date and to verify them against the band.
- D. Leave the band in place; a name band from one facility can be used in another facility.
Correct Answer: B
Rationale: Replacing the band ensures the medical record number matches the current facility, preventing errors during procedures.