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Which of these clients is the priority for the nurse to report to the public health department within the next 24 hours?
- A. An infant with a positive culture of stool for Shigella
- B. An elderly factory worker with a lab report that is positive for acid-fast bacillus smear
- C. A young adult commercial pilot with a positive histopathological examination from an induced sputum for Pneumocystis carinii
- D. A middle-aged nurse with a history of varicella zoster virus and with crops of vesicles on an erythematous base that appear on the skin
Correct Answer: B
Rationale: Tuberculosis is a reportable disease because persons who had contact with the client must be traced and often must be treated with chemoprophylaxis for a designated time.
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A nurse is returning phone calls in a pediatric clinic. Which of the following reports most requires the nurse's immediate attention and phone call?
- A. An untoward, adverse drug reaction associated with the quinolones is tendon rupture.
- B. Electrolyte imbalance has not been associated with the group, and antibiotic-associated colitis is most common in augmentin and penicillin groups.
- C. A 7 year-old boy has been having a low fever and headache for the past 3 days that has history of an anterior knee wound.
- D. A 7 year-old girl that had a cast on her right ankle is complaining of itching.
Correct Answer: B
Rationale: An untoward, adverse drug reaction associated with the quinolones is tendon rupture. Electrolyte imbalance has not been associated with the group, and antibiotic-associated colitis is most common in augmentin and penicillin groups.
Which statement by the nurse is appropriate when directing an unlicensed assistive personnel (UAP) to assist a 69 year-old surgical client to ambulate for the first time?
- A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
- B. If the client is dizzy on standing, ask him to take some deep breaths.
- C. Assist the client to the bathroom at least twice on this shift.
- D. After you assist him to the chair, let me know how he feels.
Correct Answer: A
Rationale: Give clear information to the UAP about what is expected for client safety. This instruction ensures the client is assessed for orthostatic hypotension before ambulating, reducing the risk of falls.
How is the information documented on incident reports used?
- A. to analyze risk categories
- B. to make sure procedures are in compliance with regulations
- C. to identify the educational needs of the staff
- D. all of the above
Correct Answer: D
Rationale: Risk management utilizes information from incident reports to perform all of the tasks identified.
When teaching a 10 year-old child about their impending heart surgery, which form of explanation meets the developmental needs of this age child?
- A. Provide a verbal explanation just prior to the surgery
- B. Provide the child with a booklet to read about the surgery
- C. Introduce the child to another child who had heart surgery 3 days ago
- D. Explain the surgery using a model of the heart
Correct Answer: D
Rationale: Explain the surgery using a model of the heart. According to Piaget, the school age child is in the concrete operations stage of cognitive development. Using a model to explain the surgery meets the child’s developmental needs for concrete and visual learning.
The nurse is discussing with the parents of the full-term newborn the infant's transportation in a vehicle. Which information should the nurse provide? Select all that apply.
- A. The infant should be restrained in a car seat located in the backseat facing the rear of the car.
- B. The infant should be restrained in a car seat located in the backseat facing the front of the car.
- C. An infant car seat may be designed only for infants; if so, obtain another one when the infant reaches the weight limit for that model.
- D. Some states and provinces in the United States and Canada have mandated the use of infant and child restraints.
- E. A car seat should have a certification label stating that it complies with federal motor vehicle safety standards.
Correct Answer: A,C,E
Rationale: A: Rear-facing car seats in the backseat are safest. C: Infant-only car seats have weight limits requiring replacement. E: Certification ensures safety compliance. B is incorrect as forward-facing is unsafe for infants.