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A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
- A. ''I think I should take my pain medication more often, since it is not controlling my pain.''
- B. ''Breathing faster will help me keep my mind off of the pain.''
- C. ''It might help me to listen to music while I'm lying in bed.''
- D. ''I don't want to walk today because I have some pain.''
Correct Answer: D
Rationale: Step 1: The client is verbalizing pain as a 2 indicating mild pain.
Step 2: The client understands the preoperative teaching if they prioritize mobility despite mild pain.
Step 3: Choice D reflects this understanding, as the client is aware of the importance of walking postoperatively.
Step 4: Choices A, B, and C do not demonstrate understanding of preoperative teaching as they focus on increasing medication, distracting from pain, and using music for comfort rather than prioritizing mobility.
Summary: Choice D is correct as it aligns with the goal of postoperative pain management, while choices A, B, and C do not address the importance of mobility in pain management.
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A registered nurse (RN) administered a patient’s morning insulin as the breakfast tray arrived at 0800. The RN performed a complete assessment at the same time. Then, the RN got busy with her other patients and did not check on the patient until 1400. At that time, she found the patient unresponsive with a blood glucose of 23. Both the breakfast and lunch tray were at the bedside untouched. Which of the following could the RN be charged with?
- A. Quasi-intentional tort
- B. Misdemeanor
- C. Negligence
- D. Juvenile offense
Correct Answer: C
Rationale: The correct answer is C: Negligence. The RN failed to monitor the patient after administering insulin, leading to a critical situation. Negligence in nursing involves a breach of duty of care that results in harm to the patient. In this case, the RN's failure to check on the patient for several hours directly contributed to the patient becoming unresponsive with dangerously low blood glucose levels. This constitutes a clear case of nursing negligence.
A: Quasi-intentional tort involves intentional actions that result in harm, such as defamation or invasion of privacy. This scenario does not involve intentional harm.
B: Misdemeanor refers to a criminal offense less serious than a felony. Negligence in nursing is typically addressed through civil, not criminal, proceedings.
D: Juvenile offense pertains to actions committed by minors. The RN is a healthcare professional, not a minor, and the offense here is related to professional negligence, not juvenile misconduct.
A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
- A. Hypotension
- B. Distended neck veins
- C. Slow capillary refill
- D. Weak, thready pulse
Correct Answer: B
Rationale: The correct answer is B: Distended neck veins. When a client has fluid volume excess, there is an accumulation of fluid in the intravascular space, leading to increased venous pressure. Distended neck veins are a classic sign of fluid overload as they indicate increased central venous pressure. Hypotension (A) is more commonly associated with fluid volume deficit. Slow capillary refill (C) and weak, thready pulse (D) are indicative of poor tissue perfusion, which is more commonly seen in fluid volume deficit rather than excess.
Two RNs are discussing the benefits of professional liability insurance. Which of the following is a reason for an RN to have a professional liability insurance policy?
- A. No expenses are involved in frivolous lawsuits.
- B. If a nurse is found guilty of malpractice, the institution can sue the nurse.
- C. Liability policies may also cover charges of libel, slander, assault, and HIPAA violations.
- D. Only doctors are sued for malpractice.
Correct Answer: C
Rationale: The correct answer is C because liability policies can indeed cover charges beyond malpractice, such as libel, slander, assault, and HIPAA violations. This is important as nurses can face legal actions related to various aspects of their practice beyond just malpractice. Option A is incorrect as expenses can still be involved in defending against frivolous lawsuits. Option B is incorrect because it states that the institution can sue the nurse, which is not the primary reason for having liability insurance. Option D is incorrect as nurses can also be sued for malpractice, not just doctors. Therefore, option C is the most comprehensive and relevant reason for an RN to have a professional liability insurance policy.
1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select one that doesn't apply)?
- A. Blood pressure
- B. Serum creatinine
- C. Chest x-ray
- D. Urine for microalbuminuria
Correct Answer: C
Rationale: Step-by-step rationale for correct answer (C):
1. Chest x-ray is not routinely recommended for monitoring complications of type 2 diabetes.
2. Annual blood pressure monitoring is crucial for assessing cardiovascular risk in diabetic patients.
3. Serum creatinine test helps evaluate kidney function, which is often impaired in diabetes.
4. Urine microalbuminuria test detects early signs of kidney damage, common in diabetes.
Summary of incorrect choices:
A: Blood pressure monitoring is essential for assessing cardiovascular risk in diabetes.
B: Serum creatinine test is important for evaluating kidney function in diabetic patients.
D: Urine microalbuminuria test helps detect early kidney damage in diabetes.
After correcting the IVF infusion rate, what should be the next step in the client's care?
- A. Notify family
- B. Discipline the previous nurse
- C. Complete an incident report
- D. Obtain legal consultation
Correct Answer: C
Rationale: The correct answer is C: Complete an incident report. This is the next step to document the error and ensure proper follow-up. It helps in analyzing the root cause, implementing preventive measures, and ensures transparency in patient care. Notifying the family (A) can wait until the situation is under control. Disciplining the previous nurse (B) should not be the immediate focus and may come after a thorough investigation. Obtaining legal consultation (D) is premature and should only be considered if the incident escalates to a legal issue.