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3881 soru

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Soru 1481Soru →

A nurse has just completed administering an intramuscular medication to a client. What is the most appropriate action for disposing of the used needle and syringe?

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Cevap: Activate the safety device and place the intact unit directly into a puncture-resistant sharps container.

Cevap

Activate the safety device and place the intact unit directly into a puncture-resistant sharps container.
Standard safety protocols dictate that to prevent accidental needlestick injuries and bloodborne pathogen exposure, used needles must have their safety mechanisms engaged immediately after use. The entire intact unit (needle and syringe) must then be discarded directly into a rigid, puncture-resistant sharps container without being detached, bent, or recapped.

Adım Adım Çözüm

1
Identify the type of waste being handled.
The item is a contaminated sharp (used needle and syringe).
Recognizing the hazard determines the correct disposal protocol according to OSHA and standard infection control guidelines.
2
Determine the safest method for handling the item immediately after use.
The nurse must engage the built-in safety mechanism without detaching or manipulating the needle.
Limiting interaction with the exposed needle minimizes the risk of accidental puncture wounds.
3
Select the appropriate disposal receptacle.
The intact unit is placed directly into a rigid, puncture-resistant sharps container.
Sharps containers protect staff and environmental services from injury, unlike soft plastic biohazard bags.

Anahtar Kavram

Sharps Safety and Standard Precautions
Soru 1482Soru →

An older adult client with acute delirium is continuously pulling at a newly inserted peripheral intravenous (IV) catheter. The primary healthcare provider has been notified. Arrange the following safety interventions in order from the least restrictive measure to the most restrictive measure.

Öğeleri doğru sıraya koymak için sürükleyin

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Cevap

The correct sequence from least restrictive to most restrictive is: attempting verbal de-escalation, concealing the IV site, applying unanchored padded hand mitts, and finally securing soft wrist restraints to the bed frame.
The standard of care for client safety requires implementing interventions starting with the least restrictive measures. Verbal interventions come first, followed by environmental modifications like concealing the site. If those fail, mild physical barriers like unanchored mitts are used. Tethered physical restraints are utilized only when all other alternatives have failed.

Adım Adım Çözüm

1
Identify the least restrictive independent nursing intervention.
Attempting verbal de-escalation is the initial step as it imposes no physical restriction on the client.
Nursing standards dictate starting with non-physical, interpersonal communication techniques before altering the environment or applying physical barriers.
2
Identify the next least restrictive environmental modification.
Concealing the IV site with a long-sleeved gown removes the visual trigger.
Out of sight, out of mind principles work well for confused clients and do not restrict their movement.
3
Evaluate physical barriers that do not tether the client.
Applying unanchored padded hand mitts prevents the client from grasping the IV line while preserving arm mobility.
Mitts are a physical barrier but are less restrictive than tying a limb to a fixed structure.
4
Identify the most restrictive intervention.
Applying soft wrist restraints tied to the bed frame is the final resort.
This severely limits physical mobility and requires strict adherence to legal guidelines, provider prescriptions, and facility restraint protocols.

Anahtar Kavram

Least Restrictive Environment and Restraint Escalation
Soru 1483Soru →

A home health nurse is visiting a 68-year-old client whose spouse died unexpectedly 6 weeks ago. The client was recently diagnosed with complicated grief and major depressive disorder, and was started on fluoxetine 3 weeks ago. Previously, the client exhibited profound psychomotor retardation, severe insomnia, and an inability to complete activities of daily living. Today, the client is fully dressed, appears noticeably energetic and calm, and states, 'I finally see things clearly now. I gave my prized vintage car to my nephew this morning because I won't be needing it anymore.' Which action is the nurse's priority?

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Cevap: Directly inquire if the client is experiencing thoughts of self-harm or has a specific suicide plan.

Cevap

The nurse must directly inquire if the client is experiencing thoughts of self-harm or has a specific suicide plan.
The client's presentation of sudden calmness and increased energy, combined with giving away prized possessions and making finalizing statements ('won't be needing it anymore'), are critical warning signs of an impending suicide attempt. This is especially concerning approximately three weeks after initiating an SSRI, as the medication provides the physical energy to carry out a suicide plan before the severe psychological despair fully resolves. The immediate priority is a direct assessment of suicidal ideation and intent to ensure client safety.

Adım Adım Çözüm

1
Analyze the client's clinical presentation and timeline of symptoms.
The client is 6 weeks post-loss, 3 weeks into SSRI therapy for complicated grief, and exhibiting sudden mood improvement with increased energy.
Differentiating between normal progression through the stages of grief and pathological changes requires assessing the timeline of interventions and behaviors.
2
Evaluate the clinical significance of the client's specific actions and statements.
Giving away a prized possession and stating 'I won't be needing it anymore' alongside sudden calmness are classic behavioral cues for an organized suicide plan.
In clients with severe depression, the energy gained from 2 to 3 weeks of SSRI therapy is often used to carry out a suicide plan before the cognitive symptoms of depression fully lift.
3
Apply prioritization principles to determine the immediate nursing focus.
The immediate threat to life (suicide risk) supersedes all other psychosocial interventions, documentation, or routine referrals.
According to basic safety principles, preserving the client's life is the absolute highest priority in any psychiatric or community health setting.
4
Select the most appropriate, direct intervention to address the primary concern.
The nurse must directly and unambiguously ask the client about suicidal ideation and intent.
Direct questioning is the only definitive way to assess immediate risk; indirect approaches or assumptions delay life-saving interventions.

Anahtar Kavram

Identifying Suicide Risk in Complicated Grief
Soru 1484Soru →

A pediatric nurse is creating a care plan for a 10-year-old client who requires a prolonged hospital stay. To best support the client's mastery of their current psychosocial developmental stage according to Erikson, which intervention should the nurse prioritize?

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Cevap: Facilitate time and provide resources for the client to complete their school assignments.

Cevap

The correct intervention is to facilitate time and provide resources for the client to complete their school assignments.
According to Erikson's theory of psychosocial development, a 10-year-old child is in the stage of Industry versus Inferiority. Children in this stage are heavily focused on learning, mastering new skills, and achieving a sense of competence. Providing time and resources for the client to continue their schoolwork helps them maintain their academic progress, achieve tangible goals, and successfully navigate this developmental stage despite being hospitalized.

Adım Adım Çözüm

1
Identify the client's age and applicable developmental stage.
The client is 10 years old, placing them in the school-age category.
Nursing interventions must be specifically tailored to the client's current age group to be effective.
2
Apply Erikson's theory of psychosocial development to the identified age.
A 10-year-old child is navigating the 'Industry versus Inferiority' stage.
Understanding the core developmental task helps the nurse select the most supportive clinical intervention.
3
Evaluate the options based on which one best supports the psychological goal of industry.
Continuing schoolwork allows the child to achieve tasks, learn, and feel competent, directly supporting the task of industry.
This aligns the nursing intervention with the primary psychological needs of the school-aged client during a disruptive hospitalization.

Anahtar Kavram

Erikson's Psychosocial Stages: Industry versus Inferiority (School-Age)
Soru 1485Soru →

A pediatric nurse conducts a well-child checkup for a 10-year-old client and discusses developmental milestones with the parents. Which statements by the parents indicate an understanding of the expected psychosocial and cognitive transitions for a school-age child? Select all that apply.

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Cevap: We will assign our child daily household chores to help build a sense of competence and achievement.; It is normal if our child prefers to socialize primarily with peers of the same gender.; We should encourage our child's new interest in collecting and organizing different types of rocks.

Cevap

The correct parental statements are those regarding assigning household chores to build competence, recognizing same-gender peer socialization, and encouraging the collection and organization of objects.
The school-age period (typically ages 6 to 12) is characterized by Erikson's stage of industry versus inferiority and Piaget's stage of concrete operations. During this time, children derive satisfaction from completing tasks (such as daily chores), develop an interest in sorting and classifying objects (like collecting rocks), and typically form same-sex peer groups during the latency phase. Statements reflecting these specific psychosocial and cognitive transitions indicate accurate parental understanding.

Adım Adım Çözüm

1
Identify the client's developmental age group.
The client is 10 years old, which places them in the school-age developmental stage (typically ages 6 to 12).
Establishing the correct age group is necessary to apply the appropriate developmental theories and milestones.
2
Apply Erikson's psychosocial theory to the school-age child.
The child is in the 'Industry vs. Inferiority' stage, meaning they need opportunities to achieve and feel capable.
Assigning regular chores allows the child to complete tasks and build a sense of industry.
3
Apply Piaget's cognitive theory to the school-age child.
The child is in the 'Concrete Operations' stage.
Children at this age can logically classify and organize concrete objects (like a rock collection), but they do not yet possess abstract, hypothetical reasoning skills.
4
Evaluate each parental statement against developmental norms to select the correct options.
Statements regarding chores, collecting objects, and same-gender peer groups align with school-age development. Statements about abstract reasoning, magical thinking, and parallel play describe other developmental stages.
Selecting only the statements that match the 10-year-old's expected development answers the question correctly.

Anahtar Kavram

School-Age Developmental Milestones (Erikson's Industry vs. Inferiority and Piaget's Concrete Operations)
Soru 1486Soru →

An advanced practice registered nurse is performing a routine health screening for a 2-year-old client. The parents express frustration, stating the child frequently screams 'no!' when given directions, snatches toys from other children without sharing, and communicates primarily using two-word combinations. During the physical examination, the nurse observes the child successfully kick a stationary ball, stack six wooden blocks, and turn the pages of a magazine one by one. Which nursing determination is most accurate based on these findings?

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Cevap: The assessed behaviors and physical abilities represent expected developmental milestones for the child's current age.

Cevap

The assessed behaviors and physical abilities represent expected developmental milestones for the child's current age.
All of the assessment findings—including negativism, parallel play, two-word phrases, kicking a ball, stacking six blocks, and turning pages individually—perfectly align with the expected physiological and psychosocial milestones of a 24-month-old toddler. No referrals or interventions are needed because the child's overall development is entirely on track.

Adım Adım Çözüm

1
Evaluate the reported psychosocial and behavioral data.
Negativism (saying 'no') and a lack of sharing (parallel play) are identified as normal behaviors for a toddler navigating the Autonomy versus Shame and Doubt stage.
To determine if the child's behavioral presentation requires psychosocial intervention.
2
Assess the reported expressive language skills.
Communication using two-word combinations is recognized as the standard linguistic milestone for a 24-month-old.
To rule out potential developmental speech delays.
3
Analyze the observed gross and fine motor abilities.
Kicking a ball, stacking six blocks, and turning pages individually precisely match the 2-year motor skill benchmarks.
To verify that physical development perfectly aligns with the child's chronological age.
4
Synthesize all clinical findings to formulate a comprehensive nursing judgment.
All data points represent normal development, indicating no need for referrals or specialized interventions.
To select the most accurate overall clinical determination based on the total assessment.

Anahtar Kavram

Toddler Developmental Milestones (24 Months)
Soru 1487Soru →

A young adult client is brought to the emergency department unresponsive, with pinpoint pupils and a respiratory rate of 6 breaths per minute. The nurse suspects an acute opioid overdose resulting from high-risk substance use. Arrange the following nursing actions in the correct order of priority from first to last.

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Cevap

The correct sequence is to first secure the airway and ventilate, then administer the opioid antagonist, follow up with continuous monitoring for re-sedation, and finally provide harm-reduction education once the client is completely stable.
In emergency situations involving high-risk substance use, such as an opioid overdose, nursing care must be prioritized using the ABC framework (Airway, Breathing, Circulation). Airway and breathing are the immediate priority when the respiratory rate is critically low. Pharmacological intervention follows to reverse the cause. Monitoring is then essential because the reversal agent often wears off faster than the ingested opioid. Finally, health promotion and harm-reduction education are provided at the end of the sequence when the client is fully stable and ready for discharge.

Adım Adım Çözüm

1
Prioritize physiological needs using the ABC framework.
Airway patency and supportive ventilation are identified as the first intervention.
Without an open airway and adequate breathing, all other interventions will fail to prevent hypoxic brain injury or death.
2
Address the underlying pharmacological cause of the emergency.
Administration of the opioid antagonist is identified as the second intervention.
Reversing the opioid toxicity restores the client's spontaneous respiratory drive.
3
Evaluate the client's response to the pharmacological intervention over time.
Continuous monitoring for re-sedation is identified as the third intervention.
Naloxone has a short half-life, meaning the client can slip back into respiratory depression if the opioid outlasts the reversal agent.
4
Incorporate health promotion and prevention strategies.
Harm-reduction education is identified as the final intervention.
Psychosocial interventions and education require a conscious, cognitively intact, and physiologically stable client.

Anahtar Kavram

Prioritization in acute substance toxicity utilizing the ABCs and the nursing process.
Soru 1488Soru →

A client who is receiving treatment for leukemia was administered a dose of intravenous cyclophosphamide 12 hours ago. The nurse is preparing to assist the client with hygiene and toileting. Which actions by the nurse indicate appropriate handling of hazardous materials and bodily fluids? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Flush the toilet twice with the lid closed after emptying the client's urinal.; Dispose of the gown and gloves worn during care in a designated yellow trace-chemotherapy waste container.; Wash hands thoroughly with soap and water immediately after removing personal protective equipment.

Cevap

The correct actions include flushing the toilet twice with the lid closed, disposing of PPE in a yellow trace-chemotherapy waste container, and washing hands with soap and water after removing PPE.
The correct actions for handling hazardous antineoplastic bodily fluids focus on minimizing environmental contamination and protecting staff. Flushing the toilet twice with the lid closed prevents the aerosolization of cytotoxic drug metabolites. Personal protective equipment worn during care is considered trace chemotherapy waste and must go into a designated yellow container. Finally, handwashing with soap and water is mandatory because alcohol-based hand sanitizers cannot deactivate or physically remove chemical residues from the skin.

Adım Adım Çözüm

1
Identify the clinical context and timeframes.
The client received intravenous cyclophosphamide (an antineoplastic drug) 12 hours ago. Bodily fluids are considered hazardous for at least 48 hours post-administration.
Determines the specific type of precautions required (hazardous chemical versus biological infectious).
2
Determine the appropriate personal protective equipment (PPE).
Handling bodily fluids requires double-gloving with chemotherapy-tested gloves and wearing a disposable, low-permeability gown.
Standard examination gloves and standard precautions are insufficient to protect against cytotoxic exposure.
3
Identify correct disposal and environmental safety methods for hazardous waste.
Trace chemotherapy waste (like used PPE) goes into yellow bins. Bodily fluids should be disposed of in a toilet that is flushed twice with the lid closed. Handwashing must be done with soap and water.
Alcohol sanitizers do not neutralize chemicals. Flushing with the lid closed prevents aerosolization. Biological waste streams (red bags) must not be mixed with chemical waste streams (yellow/chemo bags).
4
Evaluate the options against safe handling protocols.
Select the options that align with flushing twice, using yellow trace-chemo bins, and washing hands with soap and water.
These actions strictly align with established guidelines for handling hazardous antineoplastic materials.

Anahtar Kavram

Safe Handling of Hazardous Antineoplastic Drugs and Excreta
Soru 1489Soru →

A client is receiving care for a confirmed enteric infection caused by Clostridioides difficile. When exiting the client's room after providing direct care, which hand hygiene method is mandatory for the nurse to use?

Cevabı ve açıklamayı göster

Cevap: Washing hands vigorously with soap and water

Cevap

Washing hands vigorously with soap and water
Clostridioides difficile is a spore-forming bacterium. Spores are highly resistant to the bactericidal effects of alcohol-based hand rubs. The only effective way to remove C. difficile spores from the hands is through the physical friction and rinsing provided by washing with soap and water.

Adım Adım Çözüm

1
Identify the pathogen and its specific transmission characteristics.
The pathogen is Clostridioides difficile (C. diff), which is a spore-forming bacterium.
Understanding the nature of the pathogen dictates the appropriate infection control measures.
2
Determine the required precautions for this specific pathogen.
C. difficile requires contact/enteric precautions, which strictly mandates soap and water for hand hygiene.
Alcohol-based sanitizers do not kill spores; mechanical friction with soap and water physically removes them from the skin.

Anahtar Kavram

Standard and Transmission-Based Precautions for Spore-Forming Organisms
Soru 1490Soru →

A clinical nurse educator is evaluating a newly licensed nurse who is caring for an older adult client with bilateral soft wrist restraints. The restraints were applied to prevent the client from dislodging a continuous bladder irrigation (CBI) catheter. Which action by the newly licensed nurse indicates a correct understanding of regulatory and safety protocols for restraint management?

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Cevap: Confirming that the physical restraint prescription is strictly time-limited to a 24-hour maximum and is not written as a PRN (as needed) order.

Cevap

The correct action is ensuring the restraint prescription is time-limited to 24 hours and is not a PRN order.
The correct answer demonstrates adherence to strict regulatory standards for restraint use. For non-violent, medical-surgical applications, a healthcare provider's prescription is only valid for a maximum of 24 hours. Furthermore, restraints can never be prescribed as a PRN (as needed) order; a new, specific prescription must be obtained each time restraints are initiated or renewed.

Adım Adım Çözüm

1
Identify the primary focus of the clinical scenario.
The scenario focuses on the safe, legal management of non-violent, medical-surgical restraints used to prevent medical device (CBI catheter) dislodgment.
Different types of restraints (behavioral vs. medical-surgical) have distinct regulatory protocols.
2
Recall the federal and clinical regulations governing restraint prescriptions.
Restraints must have a specific, time-limited order (typically 24 hours for medical-surgical use) and PRN (as needed) orders are explicitly forbidden.
This prevents clients from being unnecessarily restrained and ensures continuous medical re-evaluation.
3
Evaluate the safety of the mechanical application described in the incorrect options.
Restraints must be tied with quick-release knots to the movable portion of the bed frame to prevent injury and allow rapid emergency removal.
Square knots delay removal in emergencies, and tying to siderails can cause severe musculoskeletal injury.
4
Analyze the delegation of tasks mentioned in the options.
Routine observation can be delegated, but any task requiring clinical assessment, such as checking neurovascular status, must be performed by the registered nurse.
Assessments fall strictly within the registered nurse's scope of practice.

Anahtar Kavram

Safe Use of Restraints and Safety Devices
Soru 1491Soru →

A nurse discovers that approximately 30 mL of a liquid antineoplastic (chemotherapy) medication has spilled onto the floor of a client's room due to a disconnected intravenous line. Which of the following actions should the nurse take to safely manage this hazardous spill? Select all that apply.

Geçerli olan tümünü seçin

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Cevap: Obtain a chemotherapy spill kit and put on the provided gown, double gloves, and face shield.; Place the saturated absorbent pads into a rigid, designated hazardous waste container.; Wash the affected floor area with a detergent solution and rinse with clear water after the spill is removed.

Cevap

The nurse should obtain a chemotherapy spill kit and don appropriate PPE, place the contaminated materials into a designated hazardous waste container, and decontaminate the floor with a detergent solution.
Safely managing an antineoplastic (chemotherapy) spill requires the nurse to first secure the area and put on specialized personal protective equipment (such as a chemo gown, double gloves, and face shield) provided in a designated spill kit. The nurse must then use highly absorbent pads to contain the liquid, dispose of all contaminated items in a rigid hazardous drug waste container, and fully decontaminate the floor with a detergent solution to remove any residual toxicity.

Adım Adım Çözüm

1
Secure the spill area immediately.
Prevents unauthorized entry and accidental physical exposure.
Safety is the immediate priority to prevent the spread of the hazardous material by foot traffic.
2
Don specialized PPE from the spill kit.
The nurse is protected from toxic exposure.
Antineoplastic agents are highly toxic and can be absorbed through the skin, mucous membranes, or inhalation.
3
Contain and clean the spill using spill kit absorbents.
The hazardous liquid is safely absorbed without strike-through.
Specialized absorbent pads prevent liquid from seeping through to the nurse's gloves, ensuring complete containment.
4
Dispose of materials in a hazardous drug waste receptacle.
Contaminated items are properly isolated from the general waste stream.
Hazardous drugs require specific trace or bulk waste containers (often yellow or black) to comply with environmental and safety regulations.
5
Decontaminate the surface area.
All remaining chemical residue is removed.
Detergent and water cleaning prevents long-term environmental contamination in the client's room.

Anahtar Kavram

Safe handling and cleanup of antineoplastic (chemotherapy) spills requires securing the area, using a specialized spill kit with appropriate PPE, and disposing of materials in designated hazardous waste containers.
Soru 1492Soru →

A registered nurse is assigned to care for an infant who is diagnosed with severe respiratory syncytial virus (RSV) and is prescribed continuous aerosolized ribavirin therapy. Recognizing the teratogenic and highly hazardous nature of this pharmacological agent, which of the following combinations of environmental controls and safety protocols must the nurse implement?

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Cevap: Initiate administration within a negative-pressure isolation room using a specialized aerosol-scavenging tent, mandate the use of N95 respirators and eye protection for all entering staff, and explicitly restrict pregnant personnel from providing care.

Cevap

The nurse must use a negative-pressure room with a scavenging system, require N95 respirators and eye protection for staff, and restrict pregnant personnel from the care environment.
Ribavirin is a highly hazardous, teratogenic antiviral medication. When administered via continuous aerosolization, it poses a severe occupational exposure risk. Therefore, it must be administered using a specialized small particle aerosol generator (SPAG) inside a negative-pressure room to prevent the spread of toxic aerosols to other areas of the unit. Healthcare workers must wear N95 respirators (as standard surgical masks cannot filter these fine hazardous particles) along with eye protection. Furthermore, due to its documented teratogenic and embryocidal properties, pregnant staff members must be strictly excluded from caring for the client or entering the room.

Adım Adım Çözüm

1
Analyze the properties of the prescribed pharmacological agent.
Ribavirin is identified as a highly hazardous, teratogenic, and embryocidal antiviral medication that is administered via continuous aerosolization.
Understanding the specific hazard profile (teratogenicity and aerosol route) is necessary to determine the required level of environmental and personal protection.
2
Determine the required environmental controls for aerosolized hazardous drugs.
A negative-pressure room (Airborne Infection Isolation Room) and an aerosol-scavenging tent (such as a SPAG unit) must be utilized.
These engineering controls prevent the escape of toxic aerosolized particles into adjacent hallways and minimize overall environmental contamination.
3
Select the appropriate personal protective equipment (PPE).
N95 respirators (or PAPRs), eye protection, gowns, and double gloves are mandated.
Standard surgical masks provide insufficient filtration against the fine particles of aerosolized ribavirin, necessitating airborne-level respiratory protection.
4
Implement administrative controls regarding staff assignment.
Pregnant personnel or those actively attempting to conceive are explicitly restricted from the client's care team and room.
Occupational exposure to ribavirin poses a severe risk of fetal harm and teratogenic effects.

Anahtar Kavram

The administration of aerosolized hazardous drugs requires a strict synthesis of negative-pressure environmental controls, specialized airborne-level PPE, and targeted administrative staff restrictions to prevent occupational exposure.
Soru 1493Soru →

A nursing team is reviewing the plan of care for a client who requires both droplet and contact precautions due to a confirmed pertussis infection and a methicillin-resistant Staphylococcus aureus (MRSA) infected wound. Which of the following actions indicate appropriate adherence to infection control protocols? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Donning a disposable gown and clean gloves prior to entering the client's room.; Wearing a standard surgical mask when providing direct care within 3 feet (1 meter) of the client.; Leaving reusable medical equipment, such as a stethoscope, in the room for dedicated use with this client.

Cevap

The appropriate actions for a client on both droplet and contact precautions include donning a gown and gloves before entering the room, wearing a surgical mask within 3 feet of the client, and dedicating reusable equipment to the client's room.
For a client with both pertussis (droplet precautions) and MRSA (contact precautions), the nurse must combine the protocols for both categories. This includes wearing a standard surgical mask when within 3 feet of the client to prevent inhalation of large respiratory droplets, and donning a disposable gown and clean gloves prior to room entry to prevent contact transmission. Additionally, leaving dedicated reusable equipment in the room minimizes the risk of indirect cross-contamination.

Adım Adım Çözüm

1
Identify the required isolation categories based on the client's dual diagnoses.
Pertussis requires droplet precautions, and an MRSA wound requires contact precautions.
Different pathogens have distinct modes of transmission, dictating specific personal protective equipment and environmental controls.
2
Determine the correct personal protective equipment (PPE) for the identified precautions.
A standard surgical mask is needed for droplet precautions, while a gown and gloves are needed for contact precautions upon room entry.
Droplets travel short distances (within 3 feet), and contact precautions prevent transmission via direct or indirect contact with the patient or environment.
3
Evaluate the environmental and transport requirements.
Negative-pressure rooms are not required, and the client only needs a standard surgical mask during transport.
Negative pressure and N95 respirators are strictly reserved for airborne precautions (e.g., tuberculosis), not droplet or contact.
4
Apply standard nursing delegation principles to the scenario.
The UAP cannot be assigned to assess the wound.
Assessment requires nursing judgment and must be exclusively performed by the registered nurse.

Anahtar Kavram

Standard and Transmission-Based Precautions
Soru 1494Soru →

A charge nurse is reviewing infection control protocols with a newly licensed nurse regarding a client diagnosed with seasonal influenza. Which of the following statements by the newly licensed nurse indicate a correct understanding of the required precautions? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: I will ensure the client is placed in a private room.; I will wear a standard surgical mask when entering the client's room.; I will place a surgical mask on the client if transport outside the room is necessary.

Cevap

The correct statements indicate that the client should be placed in a private room, the nurse should wear a standard surgical mask upon entry, and the client should wear a surgical mask during transport.
Seasonal influenza requires droplet precautions. The core interventions for droplet precautions include placing the client in a private room, the healthcare provider wearing a standard surgical mask upon entering the room, and having the client wear a surgical mask if transport outside the room is unavoidable.

Adım Adım Çözüm

1
Identify the mode of transmission for seasonal influenza.
Influenza is transmitted via large respiratory droplets.
Knowing the pathogen's mode of transmission dictates the specific isolation tier required.
2
Determine the appropriate transmission-based precautions for droplet transmission.
Droplet precautions require a private room, a standard surgical mask for healthcare workers entering the room, and a surgical mask for the client during transport.
These interventions specifically block the transmission of large droplets that travel short distances (usually 3 to 6 feet).
3
Evaluate each statement made by the newly licensed nurse against standard droplet precautions.
The statements regarding a private room, staff wearing a surgical mask, and the client wearing a surgical mask during transport are correct. Statements regarding N95 respirators, negative-pressure rooms, and mandatory routine gowns/gloves describe airborne and contact precautions.
Differentiating between isolation tiers ensures safe and effective care while preventing the misuse of resources.

Anahtar Kavram

Droplet precautions require placing the client in a private room and wearing a standard surgical mask when providing care. If the client must leave the room, they must wear a surgical mask.
Soru 1495Soru →

A registered nurse in a community clinic is conducting an initial intake for a newly registered 52-year-old male client. The client has a body mass index (BMI) of 31, a 25-pack-year smoking history, and continues to smoke half a pack of cigarettes daily. He reports feeling healthy and has not seen a healthcare provider in over a decade. Based on current evidence-based guidelines, which of the following secondary prevention health screenings are indicated for this client? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Low-dose computed tomography (LDCT) of the chest; Colorectal cancer screening via colonoscopy or a stool-based test; Type 2 diabetes mellitus screening using a hemoglobin A1c level

Cevap

The indicated secondary prevention screenings for this client include low-dose computed tomography (LDCT) of the chest, colorectal cancer screening, and type 2 diabetes mellitus screening.
Based on current national guidelines, this 52-year-old client requires three specific secondary prevention screenings. First, annual lung cancer screening with low-dose computed tomography (LDCT) is recommended for adults aged 50 to 80 who have a 20 pack-year smoking history and currently smoke. Second, colorectal cancer screening is universally recommended for adults beginning at age 45. Third, screening for type 2 diabetes is indicated for adults aged 35 to 70 who are overweight or obese (BMI ≥ 25). These interventions correctly represent secondary prevention aimed at early detection.

Adım Adım Çözüm

1
Analyze the client's demographic and health profile.
The client is a 52-year-old male with a BMI of 31 (obese) and a 25-pack-year smoking history who currently smokes.
Identifying exact age and specific high-risk factors is required to apply evidence-based screening guidelines.
2
Evaluate clinical indications for cancer and metabolic screenings.
LDCT is indicated due to age >50 and >20 pack-years; colorectal screening is indicated due to age >45; diabetes screening is indicated due to age >35 and BMI >25.
These specific health screenings match the client's age and risk profile for early disease detection (secondary prevention).
3
Differentiate between levels of prevention for the vaccine option.
While the recombinant zoster vaccine is age-appropriate (50+), it is an immunization (primary prevention).
The question specifically asks the nurse to identify secondary prevention (screening) interventions.
4
Evaluate the age criteria for the remaining diagnostic screenings.
Abdominal aortic aneurysm (AAA) screening is for men aged 65-75. Routine cognitive screening is reserved for older adults.
Applying geriatric screening guidelines to middle-aged adults leads to inappropriate testing.

Anahtar Kavram

Secondary prevention focuses on the early detection of disease through evidence-based health screenings tailored to a client's specific age, biological sex, and risk factors (e.g., smoking history, BMI).
Soru 1496Soru →

A community health nurse is evaluating a 22-year-old client who admits to actively injecting illicit drugs. The client states, "I know it is bad for me, but I am not ready to go to rehab or stop right now." Which of the following nursing interventions best demonstrates the principle of primary harm reduction for this client?

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Cevap: Providing the location and hours of a local clean needle and syringe exchange program.

Cevap

The intervention that best demonstrates harm reduction is providing the location and hours of a local clean needle and syringe exchange program.
The correct answer aligns perfectly with the core philosophy of harm reduction. This public health approach accepts that if a client is not ready or able to stop a high-risk behavior, the immediate nursing priority is to minimize the associated dangers, such as the transmission of bloodborne pathogens through shared needles.

Adım Adım Çözüm

1
Identify the client's current clinical situation.
The client is engaging in a high-risk behavior (intravenous drug use) but is not ready for cessation or abstinence-based treatment.
Understanding the client's readiness to change dictates which level of intervention is appropriate.
2
Define the goal of the nursing action based on the stem.
The nurse must select an intervention that aligns with the principle of 'harm reduction'.
The question specifically asks for a harm reduction strategy rather than a cessation strategy.
3
Evaluate the options against harm reduction principles.
Providing access to clean needles directly mitigates the risk of transmitting bloodborne infections without demanding immediate abstinence.
Harm reduction acknowledges that if a client cannot stop a high-risk behavior, the immediate priority is to keep them as safe as possible and prevent secondary complications.

Anahtar Kavram

Harm Reduction Principles in High-Risk Behaviors
Soru 1497Soru →

A nurse in an outpatient clinic is developing a teaching plan for a 15-year-old client who was recently diagnosed with type 1 diabetes mellitus. Which intervention should the nurse prioritize to best support the client's psychosocial development and promote adherence to the treatment regimen?

Cevabı ve açıklamayı göster

Cevap: Facilitate an opportunity for the client to interact with a peer support group of adolescents managing the same condition.

Cevap

Facilitate an opportunity for the client to interact with a peer support group of adolescents managing the same condition.
According to Erikson's theory of psychosocial development, adolescents (ages 12-18) are in the stage of Identity versus Role Confusion. During this period, the peer group becomes the most significant influence on behavior, self-esteem, and identity formation. When an adolescent is diagnosed with a chronic illness, they often feel isolated and 'different' from their peers, which can lead to non-adherence. Connecting the client with a peer support group leverages their developmental need for peer acceptance, normalizes their condition, and provides relatable role models, making it the most effective strategy to promote adherence.

Adım Adım Çözüm

1
Identify the client's developmental stage based on age.
The client is 15 years old, placing them in adolescence.
Understanding the age determines the appropriate psychosocial and cognitive framework (Erikson's Identity vs. Role Confusion and Piaget's Formal Operations).
2
Analyze the primary psychosocial needs of the adolescent stage.
Adolescents seek autonomy, form their identity, and are heavily influenced by their peer group.
Nursing interventions must align with what motivates the client to ensure adherence to a chronic illness regimen.
3
Evaluate the given interventions against adolescent developmental needs.
Connecting the client with a peer support group leverages their natural reliance on peer relationships, normalizing the illness and integrating it into their developing identity.
Other options use approaches suited for younger children or rely on future-oriented fear, which is ineffective due to the adolescent's 'personal fable' of invulnerability.

Anahtar Kavram

Adolescent Psychosocial Development and Chronic Illness
Soru 1498Soru →

A nurse is preparing to enter the room of a client placed on contact and droplet precautions. Arrange the steps for donning (putting on) personal protective equipment (PPE) in the correct sequence from first to last.

Öğeleri doğru sıraya koymak için sürükleyin

Cevabı ve açıklamayı göster

Cevap

The correct sequence for donning PPE is to first perform hand hygiene, then put on the isolation gown, followed by the surgical mask, then the face shield, and finally put on clean gloves.
According to standard infection control guidelines from organizations like the CDC, the correct sequence for donning PPE ensures maximum protection and prevents self-contamination. The process begins with hand hygiene. Next, the gown is donned to cover the torso and clothing. Then, the mask is secured to protect the respiratory tract, followed by the face shield for eye protection. Finally, gloves are put on last, pulled securely over the cuffs of the gown to prevent any skin exposure.

Adım Adım Çözüm

1
Perform hand hygiene.
Hands are clean and ready to handle protective equipment safely.
Reduces the risk of transferring pathogens to the clean PPE prior to wearing it.
2
Put on the isolation gown.
The nurse's torso, arms, and clothing are covered.
Provides a large foundational barrier against infectious materials in the client's environment.
3
Put on the surgical mask.
The nose and mouth are protected.
Prevents the inhalation of droplet-transmitted pathogens.
4
Put on the face shield.
The eyes and upper face are shielded.
Acts as a critical barrier against potential splashes, sprays, or large infectious droplets.
5
Put on clean gloves.
Hands and wrists are completely covered and sealed.
Putting gloves on last allows the nurse to stretch the gloves over the gown cuffs, maintaining a continuous barrier.

Anahtar Kavram

Sequence for donning Personal Protective Equipment (PPE)
Soru 1499Soru →

A pediatric oncology nurse is caring for a 7-year-old client who is transitioning to the actively dying phase. The client's parents and 4-year-old sibling are present at the bedside. Which of the following nursing actions are most appropriate to support the family through the anticipatory grief process? Select all that apply.

Geçerli olan tümünü seçin

Cevabı ve açıklamayı göster

Cevap: Use clear, concrete terms to explain to the 4-year-old sibling that the client's body will stop working.; Encourage the parents to participate in physical care activities, such as providing oral care, if they express interest.; Offer periods of therapeutic silence while remaining physically present in the client's room.

Cevap

The appropriate nursing actions include using clear and concrete terms to explain death to the preschool-aged sibling, encouraging the parents to participate in physical care activities, and offering periods of therapeutic silence while remaining present in the room.
Using clear, concrete terms to explain death is essential for a 4-year-old due to their literal cognitive development stage. Encouraging parental participation in physical care empowers the parents, helps maintain their parental identity, and facilitates the anticipatory grieving process. Furthermore, providing therapeutic silence and physical presence demonstrates profound empathy and support without risking the use of minimizing verbal statements.

Adım Adım Çözüm

1
Analyze the developmental stage of the 4-year-old sibling.
The sibling is in the preschool stage, characterized by literal and magical thinking.
To determine the most appropriate and safe way to communicate about death without causing unintended phobias.
2
Evaluate the proposed communication statements for therapeutic value.
Clichés and equating death to sleep are non-therapeutic and potentially harmful to the grieving process.
Therapeutic communication should validate the client's unique feelings and provide accurate, developmentally appropriate information.
3
Determine appropriate supportive interventions for parents experiencing anticipatory grief.
Encouraging participation in basic care and providing a silent, supportive presence are highly effective.
These actions empower the parents, validate their emotional experience, and prevent feelings of helplessness.
4
Assess the scope of practice for delegation regarding family psychosocial needs.
Initial psychosocial, cultural, and spiritual assessments must be conducted by the RN.
Assessments require nursing judgment and are strictly outside the scope of practice for a UAP.

Anahtar Kavram

Therapeutic Management of Anticipatory Grief and Pediatric Developmental Considerations
Soru 1500Soru →

A client on a medical-surgical unit is confused and continuously attempts to get out of bed, posing a significant risk for falls. Which action should the nurse implement first as a less restrictive alternative to a physical restraint?

Cevabı ve açıklamayı göster

Cevap: Activating a weight-sensitive bed alarm to alert staff when the client attempts to exit the bed

Cevap

Activating a weight-sensitive bed alarm to alert staff when the client attempts to exit the bed
The correct action demonstrates the use of a less restrictive alternative. A bed alarm promotes safety by notifying staff of movement without confining the client or restricting their physical freedom.

Adım Adım Çözüm

1
Analyze the client's situation and the goal of care.
The confused client is at risk for falls, and the goal is to maintain safety using the least restrictive measures possible.
Nursing standards dictate that physical and chemical restraints are interventions of last resort.
2
Evaluate the provided options to identify the intervention that maintains safety without restricting movement.
Using a bed alarm provides early warning to staff without restraining the client, whereas raising four side rails is considered a restraint.
Bed alarms meet the legal and ethical criteria for a less restrictive alternative to physical restraints.

Anahtar Kavram

Less Restrictive Alternatives to Restraints
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