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Which of the following instructions should the nurse include?
- A. Mark the edges of the doorway to the house with tape.
- B. Remove loose rugs from the home to prevent falls.
- C. Place soft cushions on all chairs to reduce discomfort.
- D. Install bright overhead lighting in the bedroom only.
Correct Answer: B
Rationale: The correct answer is B: Remove loose rugs from the home to prevent falls. This instruction is crucial in preventing falls, especially for elderly individuals who may have balance issues. Loose rugs are a common tripping hazard and removing them can significantly reduce the risk of falls. Marking the edges of the doorway with tape (A) may not be effective in preventing falls as it does not address the actual hazards. Placing soft cushions on all chairs (C) does not directly address fall prevention and may not be suitable for all individuals. Installing bright overhead lighting in the bedroom only (D) is important for visibility but does not address other fall risks in the home.
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Which statement should the nurse include in the teaching?
- A. The test should be performed after your baby is 24 hours old.
- B. Genetic screening is only necessary if there is a family history of genetic disorders.
- C. Your baby cannot eat before the genetic screening test.
- D. If the first test is abnormal, no further testing is needed.
Correct Answer: A
Rationale: The correct answer is A because it accurately states the timing for performing the genetic screening test, which should be after the baby is 24 hours old to ensure accurate results. Choice B is incorrect because genetic screening may be recommended for all newborns, not just those with a family history. Choice C is incorrect because babies can eat before the test. Choice D is incorrect as further testing may be required if the initial results are abnormal.
Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 mL.
- B. The client has a good appetite and ate well before surgery.
- C. The client's family visited during the recovery period.
- D. The client's call light is within reach.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 mL. This statement is important for the receiving nurse to know as it provides crucial information about the client's condition post-surgery. It helps in monitoring for signs of hemorrhage or other complications. The other choices (B, C, D) are not essential for the hand-off report as they do not directly impact the client's immediate care or safety. Choice B is subjective and not a clinical observation. Choice C is about the client's family, which is not pertinent to the client's medical status. Choice D is a general safety measure and not specific to the client's condition.
Which finding should the nurse expect?
- A. Spotting
- B. Painless, bright red vaginal bleeding
- C. Soft, relaxed, and non-tender uterus
- D. Fundal height greater than expected for gestational age
- E. Fetal heart rate within normal limits unless significant blood loss occurs
Correct Answer: B
Rationale: The correct answer is B: Painless, bright red vaginal bleeding. This finding is indicative of placenta previa, a condition where the placenta partially or completely covers the cervix. The bright red color indicates fresh bleeding. Spotting (choice A) is more commonly associated with implantation bleeding in early pregnancy. A soft, relaxed, and non-tender uterus (choice C) is not specific to any particular condition. A fundal height greater than expected for gestational age (choice D) could indicate fetal macrosomia or polyhydramnios, but it is not related to the scenario described. While fetal heart rate within normal limits (choice E) is important, it is not the most relevant finding in this case.
Which actions should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance.
- C. Report the findings to the appropriate authorities, following facility protocol.
- D. Take photographs of the injuries if permitted, as part of the documentation process.
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment.
Correct Answer: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.
Which of the following actions should the nurse plan to take?
- A. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
- B. Prime the transfusion tubing with lactated Ringer's solution.
- C. Administer the transfusion through a 24-gauge IV catheter.
- D. Infuse the blood over a maximum of 6 hours.
Correct Answer: A
Rationale: The correct answer is A. Using a solution of 0.9% sodium chloride to flush the transfusion tubing is essential to ensure compatibility and prevent potential reactions between the blood product and other solutions. This is a standard practice to maintain the integrity of the blood product and prevent contamination. Flushing with lactated Ringer's solution (B) would introduce a different electrolyte composition that may affect the blood product. Administering the transfusion through a 24-gauge IV catheter (C) may not be appropriate for blood transfusions due to the risk of hemolysis or clotting. Infusing the blood over a maximum of 6 hours (D) is a general guideline for blood transfusions but is not the immediate action the nurse should plan to take.