What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?
- A. Mrs. Guevarra makes the assignment to instruct the staff member
- B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
- C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
- D. Mrs. Guevarra must know how to perform the task being delegated
Correct Answer: C
Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.
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A nurse is providing preventative information to a group of parents with toddlers about choking. Which food item should the nurse recommend for this age group?
- A. Banana slices
- B. Popcorn
- C. Hot dogs
- D. Carrot sticks
Correct Answer: A
Rationale: Banana slices are the most suitable food option for toddlers to prevent choking. Toddlers are at a higher risk of choking due to their small airways and developing chewing abilities. Banana slices are soft, easy to chew, and less likely to cause choking compared to other options. Popcorn and hot dogs are common choking hazards for young children due to their shape and texture. While carrot sticks may be a healthy choice, they can also pose a choking risk due to their hardness and shape. Therefore, recommending banana slices to parents of toddlers is the safest choice to prevent choking incidents, making choice 'A' the correct answer. Choices 'B', 'C', and 'D' are incorrect because they can potentially cause choking in toddlers.
24 hours after the creation of a colostomy, what should Nurse Violy identify as the normal appearance of the stoma?
- A. Pink, moist, and slightly protruding from the abdomen
- B. Gray, moist, and slightly protruding from the abdomen
- C. Pink, dry, and slightly protruding from the abdomen
- D. Red, moist, and slightly protruding from the abdomen
Correct Answer: A
Rationale: Following colostomy surgery, a healthy stoma should appear pink, moist, and slightly protruding from the abdomen, which is why option 'A' is the correct answer. A gray stoma (choice 'B') could indicate poor blood supply or necrosis, which is a serious complication. A dry stoma (choice 'C') is also not normal as it should be moist; a dry stoma may suggest dehydration or other complications. While a stoma can appear red (choice 'D'), this is not typically the normal color; it should usually be pink. Therefore, it's important for healthcare professionals to correctly identify the normal and abnormal appearances of a stoma to ensure proper patient care.
Which food would benefit an anemic patient by increasing their intake?
- A. Beef
- B. Apples
- C. White bread
- D. Fish
Correct Answer: A
Rationale: An anemic patient would benefit from increasing their intake of beef. Beef is an excellent source of heme iron, which is critical for treating anemia. Heme iron is absorbed more readily by the body compared to non-heme iron found in plant-based foods. Apples and white bread, while healthy, do not contain significant amounts of heme iron. Fish, although it does contain iron, it's non-heme iron, which is not as efficiently absorbed by the body as heme iron, hence less effective in treating anemia.
You notice that Miss Kate, a bread vendor, receives and changes money, then holds the bread without washing her hands. As a nurse, what should you say to Miss Kate?
- A. Miss, don't touch the bread, I'll be the one to pick it up.
- B. Miss, please wash your hands before you pick up the bread.
- C. Miss, use a pick-up forceps when picking up the bread.
- D. Miss, your hands are dirty, I guess I'll try another bread shop.
Correct Answer: B
Rationale: The correct answer is B, as it emphasizes the importance of hygiene in food handling, which is crucial to prevent the spread of germs and diseases. The other options do not address the root of the issue, which is the unhygienic handling of food. Option A avoids direct confrontation but does not educate the vendor on proper hygiene. Option C, although it suggests a hygienic method, may not be practical or available in all situations. Option D is an avoidance strategy rather than a way to address the problem.
Which individual would be at the greatest risk for deficiencies in water-soluble vitamins?
- A. An individual who regularly consumes fruits and vegetables.
- B. An individual with a high intake of dairy products.
- C. An individual who consumes a diet high in processed foods.
- D. An individual who frequently eats organ meats.
Correct Answer: C
Rationale: The correct answer is 'An individual who consumes a diet high in processed foods.' Processed foods are often deficient in water-soluble vitamins such as vitamin C and B vitamins, which can lead to deficiencies. On the other hand, fruits, vegetables, and organ meats are rich sources of these vitamins, so individuals who consume these regularly are less likely to develop deficiencies. While dairy products do contain some water-soluble vitamins, they are not depleted as quickly as they are in a diet high in processed foods, making a deficiency less likely.