Nokea
A nurse is talking with the partner of a client who has dementia. The client's partner expresses frustration about finding time to manage household responsibilities while caring for their partner. The nurse should identify that the partner is experiencing which of the following types of role-performance stress?
- A. Role ambiguity
- B. Sick role
- C. Role overload
- D. Role conflict
Correct Answer: C
Rationale: The correct answer is C: Role overload. Role overload occurs when an individual feels overwhelmed by the demands of multiple roles, leading to stress and difficulty in managing responsibilities. In this scenario, the partner is struggling to balance caring for their partner with dementia and managing household responsibilities, indicating an excessive workload.
A: Role ambiguity refers to uncertainty about expectations and responsibilities in a role, which is not evident in the scenario.
B: Sick role pertains to the behavior and expectations of individuals who are ill, which is not the focus of the partner's stress.
D: Role conflict involves conflicting demands from different roles, which is not the primary issue in this situation.
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A nurse is reviewing evidence-based practice principles about administration of oxygen therapy with a newly licensed nurse. Which of the following actions should the nurse include?
- A. Regulate the flow rate by aligning the rate with the top of the ball inside the flow meter.
- B. Regulate oxygen via nasal cannula at flow rate of no more than 6 L/min.
- C. Make sure the reservoir bag of a partial rebreathing mask remains deflated.
- D. Use petroleum jelly to lubricate the client's nares face and lips.
Correct Answer: B
Rationale: The correct answer is B: Regulate oxygen via nasal cannula at a flow rate of no more than 6 L/min. This is the appropriate action for administering oxygen therapy to prevent oxygen toxicity. Oxygen should be delivered at the lowest effective flow rate to minimize the risk of complications. Choices A, C, and D are incorrect. A is incorrect because the flow rate should be aligned with the bottom of the ball in the flow meter, not the top. C is incorrect because the reservoir bag of a partial rebreathing mask should be inflated to ensure adequate oxygen delivery. D is incorrect because petroleum jelly should not be used in oxygen therapy due to the risk of fire hazard.
A nurse is preparing an education program for staff about advocacy. Which of the following information should the nurse include?
- A. Advocacy ensures clients' safety health and rights
- B. Advocacy ensures that nurses are able to explain their own actions.
- C. Advocacy ensures that nurses follow through on their promises to clients.
- D. Advocacy ensures fairness in client care delivery and use of resources.
Correct Answer: A
Rationale: The correct answer is A because advocacy in nursing involves actively supporting and promoting clients' safety, health, and rights. Advocacy ensures that nurses prioritize the well-being and best interests of their clients, advocating for their needs and empowering them to make informed decisions about their care. The other choices are incorrect because B focuses on self-explanation rather than client-centered advocacy, C is more about accountability than advocacy, and D touches on fairness but does not directly address the core concept of advocacy for clients' safety, health, and rights.
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?
- A. Increase in hematocrit.
- B. Increase in respiratory rate.
- C. Decrease in heart rate.
- D. Decrease in capillary refill time.
Correct Answer: C
Rationale: The correct answer is C: Decrease in heart rate. Administering 0.9% sodium chloride would help rehydrate the client, leading to an increase in blood volume and improved cardiac output. As a result, the heart doesn't have to work as hard, leading to a decrease in heart rate, indicating successful treatment.
Incorrect choices:
A: Increase in hematocrit - This would indicate dehydration, not successful treatment.
B: Increase in respiratory rate - This could be a sign of respiratory distress, not related to fluid volume correction.
D: Decrease in capillary refill time - This could indicate improved peripheral circulation, but not a direct indicator of successful fluid resuscitation.
A nurse is responding to a call light and finds a client lying on the bathroom floor. Which of the following actions should the nurse take first?
- A. Check the client for injuries.
- B. Move hazardous objects away from the client.
- C. Notify the provider.
- D. Ask the client to describe how she felt prior to the fall.
Correct Answer: A
Rationale: The correct action is A: Check the client for injuries. This is the first priority to ensure the client's immediate safety and well-being. By assessing for injuries first, the nurse can determine the severity of the situation and provide appropriate care. Moving hazardous objects (B) can wait until the client's safety is ensured. Notifying the provider (C) can be done after assessing the client's condition. Asking the client to describe how she felt prior to the fall (D) is important but not as urgent as checking for injuries.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider's statement in the medical record.
- B. Consult the facility's risk manager.
- C. Complete an incident report.
- D. Notify the nursing manager.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should document the provider's statement in the medical record. This is important for legal and communication purposes. By documenting the surgeon's instructions, the nurse ensures that the care provided is well-documented and can be tracked for continuity of care. It also serves as evidence that the nurse followed the provider's orders appropriately.
Summary:
B: Consulting the facility's risk manager is not necessary at this point as the situation does not involve a risk management issue.
C: Completing an incident report is not warranted as there is no indication of an incident or error that has occurred.
D: Notifying the nursing manager is not the immediate action required in this situation. The nurse should prioritize following the provider's instructions and documenting the communication.