Nurse Gayle is guided that the initial step of delegation is ______.

Correct Answer: C

Rationale: The initial step of delegation is to determine the competency level of the staff for the task being given. Before delegating a task, a nurse must assess the knowledge, skills, and abilities of the staff member to ensure that they are competent and capable of performing the task safely and effectively. This step is crucial in ensuring that tasks are delegated appropriately and that quality patient care is maintained. By determining the competency level of the staff, Nurse Gayle can make informed decisions about delegation, provide appropriate support and resources, and facilitate effective communication throughout the delegation process.

Correct Answer: C

Rationale: Tetanus toxoid provides long-lasting active immunity. When a person is vaccinated with tetanus toxoid, their immune system is stimulated to produce antibodies against the tetanus toxin. These antibodies provide protection against tetanus infection by recognizing and neutralizing the toxin if the person is exposed to the bacteria that causes tetanus in the future. This active immune response can last for many years, providing ongoing protection against tetanus. However, booster doses are recommended every 10 years to maintain adequate levels of protection.

Correct Answer: C

Rationale: The member of the health team responsible for preparing pre-operative orders for a patient undergoing surgery, such as a coronary arterial bypass graft (CABG), is typically the anesthesiologist. Anesthesiologists are specialized physicians who are trained to administer anesthesia and manage the patient's well-being during surgery. They are responsible for assessing the patient's medical history, determining the appropriate anesthesia plan, and prescribing pre-operative medications. Cardiologists focus on diagnosing and treating heart conditions, surgeons perform the actual surgical procedure, and medical internists specialize in the diagnosis and non-surgical treatment of internal diseases. The anesthesiologist plays a crucial role in ensuring the safety and comfort of the patient before, during, and after surgery.

Correct Answer: B

Rationale: The statement that the preschooler can alternate feet when climbing is not true. Typically, preschoolers at this age group are still developing their coordination and may not have mastered the skill of alternating feet while climbing. It is more common for them to use one foot after the other while climbing. This skill usually requires more advanced motor development and coordination, which may come later in the preschool years.

Correct Answer: D

Rationale: Weight reduction is the most important focus in the health teachings provided by the nurse. Maintaining a healthy weight is crucial for overall well-being and can significantly reduce the risk of various health conditions such as heart disease, diabetes, and certain cancers. By emphasizing weight reduction, the nurse can help improve the patient's overall health and quality of life. Jogging a mile a day and vigorous exercise are beneficial for weight management, but it is important to address the root cause of potential health problems which in this case may be excess weight. Moreover, emphasizing the importance of weight reduction does not necessarily mean encouraging extreme dieting; instead, it involves promoting a balanced and healthy approach to eating and physical activity.

Correct Answer: A

Rationale: A patient with a severe viral infection exhibiting reduced levels of circulating lymphocytes is likely due to the apoptosis of infected lymphocytes. When a virus enters the body, it can infect and replicate within lymphocytes, subsequently triggering the immune system to induce apoptosis in infected cells to prevent further spread of the virus. This process is part of the body's defense mechanism to control the viral infection. As a result, the circulating lymphocyte levels may decrease as infected lymphocytes are targeted for apoptosis. This phenomenon helps to limit viral replication and spread within the body, thereby aiding in the immune response to eliminate the virus.

Correct Answer: B

Rationale: The patient is presenting with symptoms consistent with cluster headache. Cluster headaches are characterized by recurrent episodes of severe unilateral (ipsilateral) headache accompanied by lacrimation (tearing from the eyes), rhinorrhea (runny nose), and ptosis (drooping of the eyelid). These headaches often occur in clusters over a period of weeks to months, hence the name "cluster headache."

Correct Answer: B

Rationale: Normal saline is the preferred solution for wound irrigation because it is isotonic and will not damage healthy tissue or delay wound healing. It helps to remove debris and pathogens from the wound, promoting a clean environment for healing. Sterile water can be used if normal saline is not available, but it may cause cellular damage if used in large volumes. Hydrogen peroxide and Betadine solution are not recommended for wound irrigation as they can be cytotoxic to the tissues and interfere with the wound healing process. It's important for the nurse to use evidence-based practice and follow recommended guidelines to promote optimal wound healing outcomes.

Correct Answer: A

Rationale: When a baby is placed on phototherapy, especially for treating jaundice, it is crucial for the nurses to put sunglasses on the newborn to protect their eyes. Phototherapy involves exposing the baby's skin to certain types of light to help break down the bilirubin causing the jaundice. However, this light can be harmful to the baby's sensitive eyes, potentially leading to eye damage or other eye-related issues if not protected adequately. Therefore, placing sunglasses on the newborn is a necessary precaution to ensure the safety and well-being of the baby's eyes during the treatment.