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Nurse is reviewing hand hygiene techniques with group of AP, which instructions should nurse include when discussing handwashing?
- A. Apply 3-5 mL of liquid soap to dry hands
- B. Wash hands with soap & water for at least 15 seconds
- C. Rinse hands with hot water
- D. Use clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: The correct answers are B and D. Option B instructs to wash hands with soap and water for at least 15 seconds, which is recommended by CDC for thorough handwashing. Option D advises using a clean paper towel to turn off hand faucets to avoid recontaminating hands after washing. This is crucial to prevent the spread of germs.
Explanation for other choices:
A: Applying 3-5 mL of liquid soap to dry hands is not mentioned in hand hygiene guidelines.
C: Rinsing hands with hot water is not necessary and can actually be harmful to the skin.
E: Allowing hands to air dry is acceptable, but it is not a crucial instruction for handwashing.
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An RN is making assignments for client care to an LPN at the beginning of shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen
- C. Providing nasopharyngeal suctioning for pneumonia client
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The LPN should question replacing cartridge & tubing on PCA pump (Choice D) because this task involves manipulating the patient's medication delivery system, which is beyond the LPN's scope of practice. LPNs are not trained to handle complex medication administration devices like PCA pumps, as this requires a higher level of knowledge and skill typically reserved for RNs. The LPN should advocate for clarification from the RN or delegate this task to someone with the appropriate training. Choices A, B, and C are within the LPN's scope of practice and do not require specialized training like manipulating a PCA pump.
A nurse is caring for an immobile patient. Which metabolic alteration will the nurse monitor for in this patient?
- A. Increased appetite
- B. Increased diarrhea
- C. Increased metabolic rate
- D. Altered nutrient metabolism
Correct Answer: D
Rationale: The correct answer is D: Altered nutrient metabolism. Immobility can lead to changes in nutrient metabolism due to decreased physical activity and muscle mass. The body may start breaking down muscle tissue for energy, leading to altered nutrient metabolism.
A: Increased appetite is not directly related to immobility and is unlikely to be a metabolic alteration seen in this patient.
B: Increased diarrhea is more likely related to gastrointestinal issues rather than a direct metabolic alteration due to immobility.
C: Increased metabolic rate is unlikely in an immobile patient as physical activity is decreased.
Therefore, D is the correct choice as it directly relates to the metabolic changes associated with immobility.
Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules, he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him because he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A. The nurse should identify the child's inability to keep up with other kids in physical activities as the priority for more assessment and intervention. This is because physical activity is crucial for a child's overall development and well-being. The inability to participate in activities like running and jumping could indicate underlying physical health issues, developmental delays, or coordination problems that need to be addressed promptly to prevent further complications. Choices B, C, and D are not as critical as they focus on behavioral or academic concerns which may be important but do not pose an immediate risk to the child's health and well-being.
Nurse observes smoke coming from under the door of the staff lounge. What is the priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The correct answer is C: Evacuate the clients. This is the priority action because ensuring the safety of the clients is the nurse's primary responsibility. Evacuating the clients from the area of potential danger is crucial to prevent harm. A: Extinguishing the fire should be left to trained personnel. B: Pulling the fire alarm is important, but evacuating clients takes precedence. D: Closing doors may help contain the fire but doesn't ensure immediate safety.
Nurse is caring for client sitting in chair & asks to return to bed. What is the priority action for the nurse?
- A. Obtain walker for client to use to transfer back to bed
- B. Call for additional personnel to assist with transfer
- C. Use transfer belt & assist client to bed
- D. Assess client's ability to help with transfer
Correct Answer: D
Rationale: The correct answer is D: Assess client's ability to help with transfer. This is the priority action because it ensures the safety of the client by determining if they are able to assist in transferring themselves back to bed. By assessing the client's ability, the nurse can prevent injury and provide appropriate assistance.
Choice A: Obtaining a walker may be helpful, but assessing the client's ability should come first to determine if it is needed.
Choice B: Calling for additional personnel is not necessary if the client can transfer independently or with minimal assistance.
Choice C: Using a transfer belt is important for safety, but assessing the client's ability should be done before assisting them.
In summary, assessing the client's ability to help with transfer is the priority to ensure safe and appropriate care.