Nokea
When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place?
- A. Client able to discuss appropriate technique
- B. Client able to demonstrate appropriate technique
- C. Client states he understands
- D. Client is able to write steps on piece of paper
Correct Answer: B
Rationale: The correct answer is B because demonstrating the appropriate technique shows psychomotor learning has taken place. This means the client has acquired the physical skills needed to draw up and mix insulin injections. Discussing technique (A) only shows verbal understanding, not necessarily physical ability. Stating understanding (C) shows cognitive learning, not physical skill. Writing steps on paper (D) demonstrates knowledge but not practical application.
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Nurse has removed sterile pack from its outside cover & placed it on clean work surface in prep for invasive procedure. Which of following flaps should nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. The rationale is to maintain sterility. By unfolding the flap farthest from the body first, the nurse can avoid reaching over the sterile field, minimizing the risk of contamination. This step-by-step approach ensures that the sterile pack remains uncontaminated and ready for the invasive procedure. Unfolding the closest flap, right side flap, or left side flap first would require the nurse to lean over the sterile field, increasing the chances of contamination. Therefore, choosing the flap farthest from the body is the most logical and sterile technique in this situation.
Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The description of linear clusters of fluid-containing vesicles with some crusting is characteristic of herpes zoster, also known as shingles. This condition is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature of herpes zoster. Allergic reaction (A) typically presents with generalized rash and itching, not linear clusters of vesicles. Ringworm (B) presents as circular, scaly lesions, not linear clusters of vesicles. Systemic lupus erythematosus (C) is an autoimmune disease that presents with a variety of symptoms, but not linear clusters of vesicles.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.
Nurse admitting client with acute cholecystitis to med-surg unit. Which of the following actions are essential to admission procedure?
- A. Explain roles of other care delivery staff
- B. Begin discharge planning
- C. Provide info about advance directives
- D. Document the client's wishes about organ donation
- E. Introduce client to his roommate
Correct Answer: A,B,C,E
Rationale: The correct choices (A, B, C, E) are essential for admission procedure. A is important to clarify roles of staff for effective care delivery. B is necessary to start discharge planning early for continuity of care. C ensures the client's preferences for future care are known. E helps the client feel comfortable by introducing them to their roommate. Choices D, F, and G are incorrect as they are not essential components of the admission procedure for acute cholecystitis.
Nurse reviewing carseat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include?
- A. Use car seat that has 3-point harness
- B. Position car seat so that infant is rear-facing
- C. Secure car seat in front passenger seat of car
- D. Put soft padding in car seat behind infants back & neck
Correct Answer: B
Rationale: The correct answer is B: Position car seat so that infant is rear-facing. This is important because rear-facing car seats are known to provide the best protection for infants in the event of a crash, as they support the head, neck, and spine. Other choices are incorrect because: A: A 3-point harness may not provide sufficient support for an infant's small body. C: Placing the car seat in the front passenger seat can be dangerous due to the presence of airbags. D: Soft padding can be a suffocation hazard and interfere with the proper fit of the harness.