the nurse manger identifies that time spent charting is excessive. the nurse manger states that "staff will form a task force to investigate & develop
... [Show More] potential solutions to the problem & then report on this at the next staff meeting." what is the nurse manger's leadership style?
transformational
upon completing a reveiw of the admission documents, a nurse identifies that an 87yr old pt. does not have an advance directive. what action should the nurse take?
inform charge nurse & give info about advance directives
a newly license nurse is concerned about time management. which action should be most effective in the initial development of a time management plan?
keep a time log for what was done during the hrs. worked
info about case management & the role of the case managemen nurse is presented during an orientation session for new nurses. which statement correctly describes an important fact about case management?
case management is a collaborative process designed to meet complex client needs
a bosnian muslim woman who does not speak english seeks care at a community center. through physical gestures, the woman indicates that she has pain originating in either the pelvic or genital region. assuming several people are available to interpret, who would be the most appropriate choice?
a female interpreter who does not know the client.
the pt. had a colon resection tow days ago. which statement should the nurse use to give an assignment to an UAP to help the client ambulate?
"have the pt. sit on the side of the bed for three to five min. before standing"
the home health nurse is visiting a pt. Dx w/ type 1 diabetes & osteoarthritis. the clients has difficulty drawing up the insulin dosage. the nurse should refer the pt. to which community resoruce person?
occupational therapist
=OT can assist a client to improve the fine motor skills needed to prepare an insulin injection. OT works w/ the taks that are needed for smaller movement to maintain ADL or for work action. PT work w/ general movment problems, mobility stability, ROM or strength training exrcises.
the 4yr old needs to have several vaccines prior to strating kindergarten. however, the nurse determines that the MMR vaccine should not be given. what is the best reason why the MMR should not be given too this child?
previous life-threatening allergic reaction to the anitbiotic neomycin.
=according to the CDC, if a person expereienced a life-threatening reaction to the antibiotic neomycin or gelatin s/he should not get the MMR. Vaccines can be give to children w/ mild cold symptoms, but it might be better to wait until they feel better. there is no relationship between the MMR & an allergy to peanuts. the CDC recommends administering the first MMR between 12 & 15 months & the second dose between 4-6yr old.
a school nurse lans to reinforce info about the most effective methods to prevent the spread of head lice in school-age children when speaking at a teacher's conference. the nurse should plan to include which info?
children should not share or wear other children's coats, hats, & scarves
parents of a 7yr old child call a clinic nurse bc their child was sent home from school due to a rash. the child, seen the day before by the health care provider, was Dx w/ 5th disease (erythema infectiosum) & is otherwise in good health. what would be the appropriate action by the nurse?
explain that this rash is no longer contagious & does nott require isolation.
=5th disease is a viral w/ an uncertain period of communicability (perhaps 1 wk prior to & 1 wk aafter the onset). children are not contagious after the appearance of the rash, which givers a "slapped cheek" appearance. isolation of the child w/ 5th disease is not necessary except in cases of hospitalized children who are immunosuppressed or having aplastic crises. the parents may need written confirmation of this from the health care provider to give to the school.
the nurse is attending an in-service about Health-care infections (HAIs). whcih factor is identified as the mnost common cause of HAIs in the acute care setting?
presennce of an indwelling catheters
=catheter-associated UTI is the most common HAIs in the acute care hospital setting. Surgical site infecitons, bloodstream, & pneumonia infections are the other categories of infections.
the nurse is discussing safety precautions w/ the parents of a child. which activity woud be most hazardous to an 18month old child?
riding in a car
=car accidents are a leading cause of death in infants & children, as well as a major cause of permanent brain damage & spinal cord injury. drowning is the 2nd most common cause of accidental death among children.
four clients are admitted to an adult medical unit on the same shift. the nurse should expect to implement airborne precautions for the client w/ which of the following Dx?
positive mantoux test w/ an abnormal chest x-ray
=the pt. who must be placed in airborn precautions is the client w/ a positive mantoux test (or PPD) & an abnormal chest film bc these could be suspicious TB lesions. the client would be place in a private rm. health care workers would have to use a HEPA filter respirator when in the rm providing care for the pt. although the confirmed AIDS w/ cytomegalovirus (CMV) is not highly communicable, it can be spread from person to person by direct contact; the virus is shed in the urine, saliva, semen, & to other body fluids.
there are a number of reasons for near misses & making medication errors, including heavy workload, inadequate staffing, distractions, interruptions, & inexperience. fatigue, sleep loss are also factors, especially for nurses working in unit w/ high acuity clients.
true
the nurse listens to report about a new admitted pt. who has a skin ulcer that's test positive for MRSA. what precautions must be taken for this hospitalized pt.? select all that apply
-perform hand hygiene after direct contact w/ the pt. & before leaving the rm.
-keep the door to the rm closed, w/ a notice for visitors
-place the client in a single rm
-keep all equipment in the client's rm for his/her sole use.
=contact precaution are recommended in acute care setting for MRSA when there's a risk for transmission or wounds that cannot be contained by dressings. the pt. should be in a single rm, w/ the door closed; the sign on the door instruct visistors to report to the nurse before entering the rm. all equipment, such as stethoscopes & BP devices, should be for the client's sole use & kept in the rm. health care workers must perform hand hypgiene (wash hands w/ soap & water) after & before direct contact w/ pt. contact precautions requires health car workers to wear gloves & gown; a face mask is no necessary for routine care.
The mother of an infant who is being treated for pesticide poisoning asks, "why is activated charcoal used?" What is an appropriate response by the nurse?
"Activated charcoal binds with the poison to limit absorption from the digestive tract"
-activate charcoal binds to the poison through the entire GI tract; it is estimated that it reduces absorption by almost 60% activated charcoal is a fine, black powder that is odorless, tasteless, & nontoxic it is often used after gastric lavage in the ER Tx of certain kinds of poisoning.
The health care team is planning a D.C. for a 90yr old pt. Dx w/ musculoskeletal weakness. Which intervention would be the priority to help prevent falls in the home?
Place night light in the bedroom & bathroom
The parents of a toddler asks "how long will our child have to sit in a car seat when riding in a car?" What would be the best response by the nurse?
"Until the child is 2yrs-old"
-the American academy of pediatric now recommends that infants & toddlers remain in rear-facing car safety seat until age 2yr old (or when they physically outgrow the limits of the seat). They can then transition to sitting in belt-position booster seats when they have reached about 4ft 9inches tall & are between 8-12yrs old. Children under age13yrs should ride in the back seat of the car
The nurse is setting up a pt.'s dinner tray. When the nurse turns her back to the pt, the pt grabs the nurse's buttocks & state he is hungry for much more than dinner. Which of the following responses by the nurse is indicated?
Complete an incident report
-to keep the therapeutic relationship intact, a nurse needs to limits on appropriate behavior & ignores bad behavior. Sexual harassment is a form of violence & is never part of the job. The nurse should report the incident to her supervisor & complete an incident report. The nurse has the right to ask not to be assigned to this pt.
The nurse is caring for a client Dx w/ hepatitis C. When reviewing the pt.'s health Hx, which of the following findings does the nurse recognize as the most likely cause for developing hepatitis C ?
Receiving blood products transfusion prior to 1992
-the pt. Who was transfused prior to blood screening for hepatitis C (1992) may show findings of hepatitis C many years later. Raw shellfish ingestion & travel to foreign countries w/ poor sewage control can increase the risk of developing hepatitis A, but not hepatitis C. Most commercial tattoos parlor are licensed & follow standard safety precautions, so the likely cause of developing hepatitis B or C after tattoo or piercing is very low.
A child is admitted w/ Dx of suspected meningococcal meningitis. Which admission orders should the nurse implement first?
Droplets Precautions
-meningococcal meningitis is an infection caused by bacteria neisseria meningitis includes droplets precautions, anti-ineffective therapy (a cephalosporins or penicillin), monitor neurological status along w/ v/s, institute seizures precautions, & maintains optimum hydration.
In the third trimester, an awake, healthy fetus should move at least 3x/hr. If the baby does not move, the mother should drink a glass of juice & then start a new count
True
The 3rd stage of labor is placental separation & expulsion & last about5-30min. The 4th stage of labor is maternal adaptation occurring 1-2hr after birth
True
When the fetus is active it's HR will accelerate by about 15beats/min above the baseline. Average FHR is about 130BPM when near term
True
Pregnancy test measure the hormone chorionic gonadotropin (hCG) in the urine or in the blood. Levels can be first detected about 12-14 days after conception & peak in the first 8-11 was of pregnancy
True
There are several findings of pregnancy during first trimester. Increase vascularity in vagina is called Chadwick sign; the increase vascularization & softness of uterine isthmus is Hegar's sign; & the softening of the cervix is Goodell's sign
True
RhoGAM is administered to Rh negative woman after any possible exposure to fetal blood such as after each ectopic pregnancy, miscarriage, abortion, or amniocentesis. RhoGAM will be given to help prevent problems associated w/ incompatible blood types in future pregnancies
True
Chloasma is a skin discoloration of pregnancy. The first breast milk is called colostrum. Colostrum is low in fat, high in carbs , protein, & anti bodies & easy for the newborn to digest.
True
Engagement means that the baby's head no longer floats freely, but has dropped down into the pelvis. In a multipara, engagement normally occurs about two was before birth
True
The normal color all over for the newborn is pink; a pink baby earns a score of 2. A baby who is pink w/ pale blue toes/feet & fingers will receive a score of 1 on the APGAR test.
True
Tapping on the glabella (flat bone between the eyebrows) causes a neurologically healthy baby to close both eyes. This is referred to as the glabella reflex.
True [Show Less]