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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.
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A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?
- A. During the admission process.
- B. As soon as the client's condition is stable.
- C. During the initial team conference.
- D. After consulting with the client's family.
Correct Answer: A
Rationale: Correct Answer: A. During the admission process.
Rationale: Discharge planning should start early to ensure a smooth transition. During admission, the nurse can assess the client's needs, resources, and support system. This allows time to address any potential barriers to discharge and create a comprehensive plan. Starting discharge planning later may lead to delays and inadequate preparation for the client's transition. Initiating discharge planning during the admission process promotes continuity of care and helps prevent readmissions.
Summary of Other Choices:
B: Waiting until the client's condition is stable may delay discharge planning and increase the risk of complications during the transition.
C: Waiting for the initial team conference may result in missed opportunities to address discharge needs promptly.
D: Involving the client's family is important, but discharge planning should start early to ensure all aspects of the plan are considered and implemented effectively.
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 in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
- A. Image A: Client sitting with legs dangling over the edge of the table and the examiner tapping below the patella with a reflex hammer.
- B. Image B: Client lying down with legs extended and the examiner tapping above the patella with a reflex hammer.
- C. Image C: Client sitting with legs crossed while the examiner taps the patella with a reflex hammer.
- D. Image D: Client standing with knees slightly bent while the examiner taps the patella with a reflex hammer.
Correct Answer: A
Rationale: The correct answer is A because the image depicts the correct technique for eliciting the patellar reflex. When assessing the patellar reflex, the client should be sitting with their legs dangling over the edge of the table, and the examiner should tap below the patella with a reflex hammer. This position allows for optimal relaxation of the quadriceps muscle and easy access to the patellar tendon, resulting in a more accurate reflex response.
Choice B is incorrect because tapping above the patella can lead to an inaccurate response as it does not target the patellar tendon directly. Choices C and D are incorrect as they involve incorrect client positions that do not facilitate the proper assessment of the patellar reflex.
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
- A. Critical pathway
- B. Situation background assessment and recommendation (SBAR)
- C. Transfer report
- D. Medication administration record (MAR)
Correct Answer: B
Rationale: The correct answer is B: Situation background assessment and recommendation (SBAR). SBAR is a structured communication tool used in healthcare to provide a concise and focused way of relaying important information between healthcare team members. It helps ensure continuity of care by including essential details such as the patient's situation, background information, assessment findings, and recommendations for further care. SBAR improves communication efficiency, reduces errors, and enhances patient safety.
Choices A, C, and D are incorrect because:
A: Critical pathway is a care plan outlining evidence-based guidelines for patient care but does not provide the detailed communication needed for continuity of care.
C: Transfer report is focused on the transfer of a patient between units or facilities and may not include all the necessary information for continuity of care during a shift change.
D: Medication administration record (MAR) is a document used to record medication administration and does not encompass the comprehensive patient information needed for effective shift handoff.
A nurse is caring for a client who has herpes zoster and asks the nurse about the use of complementary and alternative therapies for pain control. The nurse should inform the client that this condition is a contraindication for which of the following therapies?
- A. Biofeedback
- B. Aloe
- C. Reflexology
- D. Acupuncture
Correct Answer: D
Rationale: The correct answer is D: Acupuncture. Herpes zoster, also known as shingles, is a viral infection that affects the nerves and causes a painful rash. Acupuncture involves inserting thin needles into specific points on the body to alleviate pain and promote healing. However, in the case of herpes zoster, the skin lesions and nerve involvement increase the risk of spreading the virus through acupuncture needles, leading to potential complications. Therefore, acupuncture is contraindicated in clients with herpes zoster to prevent the spread of the virus.
A: Biofeedback, B: Aloe, and C: Reflexology are not contraindicated for clients with herpes zoster. Biofeedback is a non-invasive technique that helps individuals control physiological processes such as reducing stress and managing pain. Aloe is a natural plant extract commonly used for its anti-inflammatory and soothing properties, which can be beneficial for skin irritations caused by herpes zoster. Reflexology is a therapeutic technique that involves applying pressure to