Nokea
When choosing a needle gauge for an intramuscular injection in a 12 year old boy. Which of the following gauges would you choose?
- A. 27 gauge
- B. 25 gauge
- C. 22 gauge
- D. 20 gauge
Correct Answer: C
Rationale: 22 gauge is recommended for school age children, toddlers, and adolescents while 23-25 gauge is recommended for infants.
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A nurse is giving shift report off to the oncoming LPN. Which of these is an inappropriate shift report?
- A. The nurse gives report to the oncoming LPN, checking a wound vac and dressing together.
- B. The nurse reports in SBAR format, noting that the client was noncompliant with their diet during the shift.
- C. The nurse reports in the hallway, SBAR format, and alerts the oncoming LPN about how rude the client was throughout the shift.
- D. The nurse reports at bedside with the oncoming LPN and discusses the client's concerns after the chart has been reviewed.
Correct Answer: C
Rationale: Report should be at the bedside, in SBAR format, and given in an objective way.
The nurse is assessing the dental status of an 18-month-old child. How many teeth should the nurse expect to examine?
- A. 6
- B. 8
- C. 12
- D. 16
Correct Answer: C
Rationale: In general, children begin dentition around 6 months of age. During the first 2 years of life, a quick guide to the number of teeth a child should have is as follows: Subtract the number 6 from the number of months in the age of the child. In this example, the child is 18 months old, so the formula is 18 - 6 = 12. An 18-month-old child should have approximately 12 teeth.
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
- A. the client has been admitted to the hospital three times in the last 2 months.
- B. the client has a Foley catheter.
- C. the client's family is available to care for him 24 hours a day.
- D. the client is ordered to continue IV antibiotics 5 days post discharge.
Correct Answer: C
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care. In fact, the nurse might see some opportunity for family education in meeting the client's needs so that less community support is needed. Frequent hospital readmissions imply that the client has not been able to manage either due to condition instability or lack of care needs being met. This is a red flag for home care services to be able to meet those needs and appropriately monitor the client. A Foley catheter is an indication for home care due to infection potential and care requirements. IV antibiotics involve home care due to maintaining line patency and assessment of the site.
A client is having an abortion in a women's clinic and the nurse caring for the client does not think the reasoning is appropriate. The nurse asks, 'Are you sure you want to do this, it can't be undone. Have you read about your other options? Adoption is always a good choice.' The client states she understands all options and is comfortable with her choice. The nurse nods and leaves the room to discuss the procedure with the physician. Which client right did the nurse violate with her actions?
- A. the client's right to make personal health decisions without interference, as the nurse tried to sway the client's decision-making and healthcare choice in the direction of not having an abortion
- B. the client's right to be left alone without unsolicited attention, as the nurse inserted herself in the client's healthcare scenario and offered uninvited advice
- C. the client's right to confidentiality, as the nurse is talking to the physician about the client and the abortion
- D. the client's right to respectful care, as the nurse clearly made it known that she did not approve of the abortion
Correct Answer: A
Rationale: A client has the right to make decisions about his or her healthcare without interference from health team members. It is our duty to respect those decisions and not try to influence patients based on our beliefs.
Which of the following behaviors is least appropriate when dealing with fellow staff members?
- A. Provide positive feedback and constructive criticism.
- B. Serve as a resource.
- C. Only report conflicts that interfere with client care.
- D. Provide input for performance evaluations.
Correct Answer: C
Rationale: When conflicts are recognized, they should be reported. Conflicts can involve all components of healthcare practice including client care, nursing staff interaction, interactions with other hospital staff, and resource use/availability.