Nokea
Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP)
indicates the most urgent need for the nurse’s assessment of the patient?
- A. Bedtime glucose of 140 mg/dL
- B. Noon blood glucose of 52 mg/dL
- C. Fasting blood glucose of 130 mg/dL
- D. 2-hr postprandial glucose of 220 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Noon blood glucose of 52 mg/dL. This value indicates hypoglycemia, which can lead to serious complications like confusion, seizures, or coma. Immediate assessment and intervention are crucial.
A: Bedtime glucose of 140 mg/dL is within the normal range.
C: Fasting blood glucose of 130 mg/dL is slightly elevated but doesn't require urgent assessment.
D: 2-hr postprandial glucose of 220 mg/dL is elevated but not as critical as hypoglycemia.
You may also like to solve these questions
What is the primary focus of a patient safety program?
- A. To reduce healthcare costs
- B. To improve clinical outcomes
- C. To enhance patient satisfaction
- D. To comply with regulatory standards
Correct Answer: C
Rationale: The primary focus of a patient safety program is to enhance patient satisfaction. This is because the ultimate goal of patient safety initiatives is to ensure that patients receive safe and high-quality care, leading to improved patient experience and satisfaction. By prioritizing patient safety, healthcare providers can build trust with patients, reduce medical errors, and prevent harm.
Why other choices are incorrect:
A: While reducing healthcare costs may be a positive outcome of a patient safety program, it is not the primary focus.
B: Improving clinical outcomes is an important goal of patient safety programs, but it is not the primary focus as patient satisfaction encompasses a broader aspect of care.
D: Compliance with regulatory standards is essential, but it is a means to achieve patient safety rather than the primary focus.
A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct Answer: A
Rationale: The correct answer is A. The elevated blood pressure of 144/82 mm Hg indicates dehydration due to vomiting and diarrhea, leading to hypovolemia. This is a compensatory mechanism by the body to maintain perfusion. Option B, urine specific gravity of 1.03, indicates concentrated urine and dehydration, but not as specific as elevated blood pressure. Option C, neck vein distention, is more indicative of heart failure or fluid overload rather than dehydration. Option D, urine specific gravity of 1.01, indicates diluted urine and is not consistent with dehydration. Therefore, based on the symptoms and the compensatory mechanism of the body, an elevated blood pressure is the most likely finding in a client with vomiting and diarrhea.
What are the advantages of using internal pools of nurses for staffing purposes?
- A. Familiarity with the hospital & Lower cost
- B. Centralization
- C. Staffing mix
- D. Staff satisfaction
Correct Answer: A
Rationale: The correct answer is A: Familiarity with the hospital & Lower cost. Internal pools of nurses are advantageous because they are already familiar with the hospital's policies, procedures, and workflow, reducing the need for extensive training. This familiarity can lead to increased efficiency and improved patient care. Additionally, utilizing internal nurses can be cost-effective as they are already on the hospital's payroll, reducing the need for external agency staff, which can be more expensive. Centralization (option B) and staffing mix (option C) are not directly related to the advantages of using internal pools of nurses. Staff satisfaction (option D) can be a potential benefit of internal pools, but it is not as directly linked to the advantages of familiarity and cost savings as option A.
When a client who is in pain refuses to be repositioned, what should the nurse consider first in making a decision about what to do?
- A. Why a decision is needed.
- B. Who actually gets to make the decision?
- C. What are the alternatives?
- D. When a decision is needed.
Correct Answer: A
Rationale: Step-by-step rationale:
1. Understanding why a decision is needed is crucial in this situation to prioritize the client's well-being.
2. The nurse needs to assess the reasons behind the client's refusal to be repositioned, considering factors such as pain level and potential harm.
3. By determining the underlying cause, the nurse can make an informed decision on the best course of action to address the client's needs promptly.
4. Considering the alternatives (choice C) is important but secondary to understanding the urgency and necessity of the decision (choice A).
5. Who makes the decision (choice B) and when it is needed (choice D) are not as critical as the rationale behind the decision-making process.
Summary:
Choice A is correct because understanding the reason for the decision is essential for prioritizing the client's well-being. Choices B, C, and D are incorrect as they do not directly address the immediate need to assess the situation and make an informed decision based on the client's condition
A client experiences an air emboli, resulting in a stroke, during an IV start. This can be classified as which type of risk?
- A. Patient dissatisfaction
- B. Medical-legal incident
- C. Medication error
- D. Diagnostic procedure
Correct Answer: D
Rationale: The correct answer is D: Diagnostic procedure. Air emboli during an IV start can lead to a stroke, making it a risk associated with a diagnostic procedure. The air emboli occurred during the IV start, which is a diagnostic procedure aimed at obtaining information about the patient's health status. Patient dissatisfaction (A) is not the main concern here, as the focus is on the medical outcome. While a medical-legal incident (B) may result from this situation, the primary classification is related to the diagnostic nature of the procedure. This incident is not primarily a medication error (C) as the main issue is the introduction of air into the bloodstream during the IV start, rather than a mistake in medication administration.