Nokea
When ambulating a frail, older adult client, the nurse should:
- A. Use the transfer belt if the client is unsteady
- B. Walk beside the client without support
- C. Encourage the client to use a walker
- D. Hold the client's arm for support
Correct Answer: A
Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.
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When orienting a newly licensed nurse on taking a telephone prescription, which statement indicates understanding of the process?
- A. A second nurse enters the prescription into the client's medical record.
- B. Another nurse should listen to the phone call.
- C. The provider can clarify the prescription when they sign the health record.
- D. I should omit the 'read back' if this is a one-time prescription.
Correct Answer: A
Rationale: The correct answer is A because a second nurse should verify and enter the prescription into the client's medical record to ensure accuracy. This step is crucial to prevent errors in transcription and administration. Choice B is incorrect as having another nurse listen to the phone call does not ensure accurate transcription. Choice C is incorrect because the provider clarifying the prescription upon signing the health record does not replace the need for proper documentation. Choice D is incorrect because the 'read back' process is essential for all telephone prescriptions to confirm accuracy and prevent errors in transcription or administration.
A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective environment
Correct Answer: C
Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.
When transferring a postoperative client from the PACU following abdominal surgery, what action should the nurse take to move the client from the stretcher to the bed?
- A. Lock the wheels on both the bed and stretcher
- B. Adjust the bed to a low position
- C. Ask the client to assist in the transfer
- D. Use a transfer sheet without locking the wheels
Correct Answer: A
Rationale: Locking the wheels on both the bed and stretcher is crucial for ensuring stability during the transfer process. This action is essential to prevent unexpected movement of the bed or stretcher, reducing the risk of injury to the client and facilitating a safe transfer. Adjusting the bed to a low position is important for the client's comfort and safety but does not directly address the immediate need for stability during the transfer. Asking the client to assist in the transfer may not be feasible immediately postoperatively, depending on their condition and the type of surgery they underwent. Using a transfer sheet without locking the wheels can introduce potential safety hazards as the bed or stretcher may move during the transfer, undermining the stability needed for a safe and effective transfer.
The mother of a 2 year-old hospitalized child asks the nurse's advice about the child's screaming every time the mother gets ready to leave the hospital room. What is the best response by the nurse?
- A. I think you or your partner needs to stay with the child while in the hospital.
- B. Oh, that behavior will stop in a few days.
- C. Keep in mind that for the age this is a normal response to being in the hospital.
- D. You might want to 'sneak out' of the room once the child falls asleep.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider is preparing to administer a subcutaneous injection of heparin. Which site is most appropriate for the healthcare provider to use?
- A. Deltoid muscle
- B. Ventrogluteal site
- C. Abdomen
- D. Dorsogluteal site
Correct Answer: C
Rationale: The abdomen is the most appropriate site for administering subcutaneous heparin injections. The abdomen has a layer of subcutaneous fat and a good blood supply, making it an ideal site for subcutaneous injections. Using the deltoid muscle for heparin injections is not appropriate as it is typically used for intramuscular injections. The ventrogluteal site is more suitable for intramuscular injections rather than subcutaneous injections. The dorsogluteal site is no longer recommended for injections due to the risk of injury to the sciatic nerve.