Nokea
A nurse is developing a care plan for a client who is in Buck's traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to assistive personnel?
- A. Ask the client to describe her pain.
- B. Check the client's pedal pulse on the right leg
- C. Observe the position of the suspended weight
- D. Remind the client to use the incentive spirometer.
Correct Answer: D
Rationale: Correct Answer: D. Remind the client to use the incentive spirometer.
Rationale:
1. Incentive spirometer use is a task that can be safely delegated to assistive personnel.
2. It is a non-invasive procedure and does not require advanced nursing skills.
3. Using the incentive spirometer helps prevent respiratory complications post-surgery.
4. Assistive personnel can remind the client to use it regularly, promoting lung expansion and preventing atelectasis.
Summary of other choices:
A: Asking the client to describe pain requires nursing assessment skills.
B: Checking the client's pedal pulse requires nursing assessment skills.
C: Observing the position of the suspended weight requires nursing judgment to adjust if needed.
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Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 milliliters.
- B. The client is a member of the board of directors.
- C. There was a total of 10 sponges used during the procedure.
- D. The client was intubated without complications.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 milliliters. This statement is crucial in a hand-off report as it provides important information about the client's condition post-procedure. It helps alert the receiving nurse to any potential complications or the need for further monitoring.
Statement B is incorrect as the client's position on the board of directors is not relevant to the client's immediate care needs and does not provide useful clinical information. Statement C, the number of sponges used, is also irrelevant to the client's immediate condition and does not impact the client's ongoing care.
Statement D, mentioning intubation without complications, could be important in certain contexts, but in this scenario, information about blood loss is more critical for the receiving nurse to be aware of.
Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.
- B. I can visit my nephew who has chickenpox S days after the sores have crusted.
- C. I can clean my cat's litter box during my pregnancy.
- D. I should wish my hands for 10 seconds with hat water after working in the garden.
Correct Answer: B
Rationale: Chickenpox sores crust over before becoming non-contagious.
Which of the following statements should the nurse include in the teaching?
- A. A nurse will draw blood from your baby's inner elbow.
- B. Your baby will be given 2 ounces of water to drink prior to the test.
- C. This test should be performed after your baby is 24 hours old.
- D. This test will be repeated when your baby is 2 months old.
Correct Answer: C
Rationale: Newborn genetic screening is most accurate when performed after the baby is 24 hours old.
Which of the following actions should the nurse plan to take?
- A. Launch a media campaign to increase awareness about industrial pollution
- B. Have a nurse from outside the community provide health lectures at the county hospital
- C. Encourage rural residents to focus health spending on tertiary health interventions
- D. Provide anticipatory guidance classes to parents through public schools
Correct Answer: D
Rationale: The correct answer is D because providing anticipatory guidance classes to parents through public schools is a proactive approach to promote health and prevent illness in the community. This action empowers parents with knowledge and skills to make informed health decisions for their children. Launching a media campaign (A) may raise awareness but may not directly impact individual behavior change. Having a nurse from outside the community provide health lectures (B) may not be as effective as someone familiar with the community's specific needs. Encouraging rural residents to focus on tertiary health interventions (C) is reactive and may not address prevention.
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
- A. Tetracycline 200 mg PO
- B. Epoetin alfa 150 units/kg three times weekly
- C. Digoxin 0.25 mg PD dally
- D. Cimetidine PO twice daily
Correct Answer: C
Rationale: The correct answer is C: Digoxin 0.25 mg PO daily. The rationale for this choice being complete is that it includes the medication name (Digoxin), dose (0.25 mg), route of administration (PO - by mouth), and frequency (daily). This prescription is clear and specific, providing all necessary information for the nurse to accurately administer the medication.
Other choices are incorrect:
A: Missing frequency information.
B: Missing route of administration and frequency.
D: Missing dose and frequency.