Nokea
Which of the following statements about security in healthcare environments is accurate?
- A. Healthcare facilities must have egress alarms on all doors, except client doors, to maintain security within the facility.
- B. All members of the healthcare facility must have education and training relating to security in the facility.
- C. Members of the healthcare facility who do not have clinical access do not need education and training relating to security in the facility.
- D. Members of the healthcare facility who have only clerical roles do not need education and training relating to security in the facility.
Correct Answer: B
Rationale: All healthcare staff, regardless of role, require security training to ensure safety. Egress alarms are not universally required, and excluding non-clinical or clerical staff is incorrect.
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The nurse is reviewing a newly hired nurse's understanding of sterile technique. Which statement, if made by the newly hired nurse, would indicate effective understanding? Select all that apply.
- A. I should open sterile packages away from my body.
- B. If the sterile field gets contaminated, I should dispose of everything and start over.
- C. One inch (2.5 cm) border around a sterile drape can be touched with clean fingers.
- D. I should apply sterile gloves on my non-dominant hand first.
- E. An object placed below my waist is considered contaminated.
Correct Answer: A,B,D,E
Rationale: Opening packages away, restarting after contamination, applying gloves correctly, and recognizing below-waist contamination are correct. The 1-inch border is non-sterile and should not be touched.
The nurse assists a client with left-sided weakness. Which of the following actions should the nurse perform when assisting this client in ambulating with a cane? Select all that apply.
- A. Place a gait belt around the client's waist.
- B. Stand on the client's left side during ambulation.
- C. Instruct the client to put the cane in the left hand.
- D. Measure the cane from the client's wrist crease.
- E. Instruct the client to put the cane in the right hand.
- F. Instruct the client to look down while ambulating.
Correct Answer: A,B,E
Rationale: A gait belt ensures safety, standing on the weaker side provides support, and the cane in the right hand aids balance. Cane height is measured to the greater trochanter, and looking down risks falls.
The nurse is caring for a client who repeatedly attempts to get up from their wheelchair unassisted and has fallen twice. The primary healthcare provider (PHCP) prescribes restraints. Which type of restraint does the nurse anticipate?
- A. Soft wrist restraints
- B. Mitten restraints
- C. Seclusion
- D. Waist belt restraint
Correct Answer: D
Rationale: A waist belt restraint prevents unassisted standing while allowing some mobility. Wrist or mitten restraints limit hand use, and seclusion is inappropriate for fall prevention.
A nurse is caring for a client with a suspected bowel obstruction who requires a nasogastric (NG) tube insertion. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Begin inserting the tube. Have the client relax and flex their head toward their chest after the tube has passed through the nasopharynx.
- B. Verify tube placement with a radiograph. Check agency policy for specific guidelines.
- C. Encourage the client to swallow by taking small sips of water when possible. Then advance the tube as the client swallows.
- D. Determine the length of the tube to be inserted. Measure the distance from the tip of the nose to the earlobe to the xiphoid process (NEX) of the sternum.
- E. Temporarily anchor the tube to the nose with a small piece of tape.
- F. Educate the client on what is going to take place. Instruct client to relax and breathe normally while occluding one naris. Then repeat this action for the other nare. Select the nostril with greater airflow.
- G. Advance the tube each time the client swallows until you reach the desired length.
Correct Answer: F,D,A,C,G,E,B
Rationale: The correct order is: educate the client (F), measure tube length (D), begin insertion (A), encourage swallowing (C), advance to desired length (G), anchor the tube (E), verify placement with radiograph (B). This sequence ensures safe and effective NGT insertion.
The nurse is teaching a client about a vegetarian diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
- A. Legumes
- B. Almond butter
- C. Grilled chicken
- D. Apricots
- E. Baked fish
- F. Seafood salad
Correct Answer: A,B,D
Rationale: Vegetarian diets exclude meat, so legumes, almond butter, and apricots are suitable. Chicken, fish, and seafood are not vegetarian.