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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.
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All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct Answer: C
Rationale: The client with an old injury does not need an emergency assessment because this is not a life-threatening or new situation or condition.
A health care agency has different receptacles for the various categories of institutional waste. Into which container should the nurse dispose of a suction canister used to collect bloody drainage from the client's NG tube?
- A. Injurious waste receptacle
- B. Hazardous waste receptacle
- C. Infectious waste receptacle
- D. Wastebasket in the client's bathroom
Correct Answer: C
Rationale: Blood and body fluids are classified as infectious waste, requiring disposal in the infectious waste receptacle.
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.
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.
A nurse is implementing a community awareness campaign about accidental poisoning. Which of the following should she teach in the class?
- A. The child should be given milk.
- B. The child should be given syrup of Ipecac.
- C. The poison control center should be contacted.
- D. The child should be taken to the ER.
Correct Answer: C
Rationale: The poison control center should be contacted first to provide expert guidance on managing the poisoning.