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1. A community health nurse is helping to reinforce teaching about hepatitis A with a group of employees at a childcare facility. Which of the following characteristics should the nurse identify as an external factor that can impede learning for the participants?
- A. High workload
- B. Limited knowledge on the subject
- C. Poor lighting
- D. Limited space in the learning area
Correct answer: C
Rationale: The correct answer is C: 'Poor lighting.' External factors such as lighting can significantly impact the learning environment, making it difficult for participants to engage effectively. Poor lighting can strain the eyes, cause discomfort, and lead to decreased concentration. Choices A, B, and D are internal factors or issues that are not directly related to the learning environment. High workload, limited knowledge on the subject, and limited space in the learning area may affect learning differently but do not impede learning through external factors like poor lighting does.
2. A healthcare provider is checking a newborn's vital signs. Which of the following methods of temperature measurement should the healthcare provider use?
- A. Rectal
- B. Axillary
- C. Oral
- D. Tympanic
Correct answer: B
Rationale: The axillary method is the most appropriate for newborns because it is non-invasive and safe. Rectal temperature measurement can be uncomfortable and poses a risk of injury, especially in newborns. Oral temperature measurement is not recommended for newborns due to their inability to cooperate and potential inaccuracies. Tympanic temperature measurement may not be as accurate in newborns compared to older children or adults.
3. A nurse is caring for a client who is 2 hours postoperative following a colon resection. Which of the following assessments is the nurse's priority?
- A. Capillary refill
- B. Bowel sounds
- C. Temperature
- D. Oxygen saturation
Correct answer: D
Rationale: The correct answer is D: Oxygen saturation. The priority assessment in this situation is oxygen saturation because postoperative clients are at risk for respiratory complications, such as hypoxia due to factors like anesthesia effects, impaired lung function, or pain interfering with deep breathing. Monitoring oxygen saturation is crucial to detect any respiratory compromise early. Capillary refill, bowel sounds, and temperature are important assessments but are not the priority in this immediate postoperative period.
4. A client receiving chemotherapy is experiencing fatigue. Which intervention should the nurse implement to manage the client's fatigue?
- A. Encourage the client to take short naps during the day
- B. Instruct the client to remain on bedrest
- C. Provide the client with a high-calorie diet
- D. Encourage the client to increase activity levels
Correct answer: A
Rationale: The correct intervention to manage fatigue in a client receiving chemotherapy is to encourage the client to take short naps during the day. Fatigue is a common side effect of chemotherapy, and allowing the client to rest can help combat this symptom. Instructing the client to remain on bedrest (Choice B) is not recommended as it may lead to deconditioning and worsen fatigue. Providing a high-calorie diet (Choice C) may be beneficial for overall nutrition but does not directly address fatigue. Encouraging the client to increase activity levels (Choice D) may exacerbate fatigue instead of alleviating it.
5. What is the appropriate intervention for fluid overload?
- A. Restrict fluid intake
- B. Administer diuretics
- C. Monitor vital signs
- D. All of the above
Correct answer: D
Rationale: The appropriate intervention for fluid overload involves a combination of measures, including restricting fluid intake to prevent further fluid accumulation, administering diuretics to help the body eliminate excess fluids, and closely monitoring vital signs to assess the patient's response to treatment. Therefore, all of the above options are correct. Restricting fluid intake alone may not be sufficient to address existing fluid overload without additional measures like diuretic therapy. Monitoring vital signs is essential to evaluate the effectiveness of the interventions and the patient's overall condition.
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