Nokea
A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?
- A. Measuring oxygen saturation for a client who has dyspnea
- B. Inserting a rectal suppository for a client who is vomiting
- C. Performing nasal hygiene for a client who has an NG tube
- D. Pouching a client's ostomy bag for a new colostomy
Correct Answer: D
Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.
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Which nursing diagnosis is commonly used among patients affected by fibromyalgia?
- A. Decreased self-care in activities of daily living related to fatigue
- B. Impaired mental functioning related to electrolyte imbalances
- C. Increased vigilance secondary to electrolyte imbalances
- D. At risk for a swallowing disorder related to fibromyalgia
Correct Answer: A
Rationale: The correct answer is A: 'Decreased self-care in activities of daily living related to fatigue.' Patients with fibromyalgia commonly experience fatigue, which can lead to decreased ability to perform self-care activities. This nursing diagnosis addresses a direct consequence of fibromyalgia. Choices B, C, and D are incorrect because they do not directly correlate with the common manifestations of fibromyalgia. Impaired mental functioning related to electrolyte imbalances and increased vigilance secondary to electrolyte imbalances are not typical presentations of fibromyalgia. 'At risk for a swallowing disorder related to fibromyalgia' is not a common nursing diagnosis associated with fibromyalgia; swallowing disorders are not a primary symptom of this condition.
What is the significance of patient advocacy in nursing?
- A. Prioritizing the needs of the healthcare team over the patient
- B. Ensuring that patients' rights and preferences are respected
- C. Limiting patient autonomy
- D. Focusing solely on clinical procedures
Correct Answer: B
Rationale: Patient advocacy in nursing entails ensuring that patients' rights and preferences are respected. This involves advocating for the patients' best interests, supporting informed decision-making, and safeguarding their autonomy. Choice A is incorrect because patient advocacy focuses on the patient's needs, not the healthcare team's. Choice C is incorrect as patient advocacy aims to empower patients and enhance their autonomy rather than limiting it. Choice D is incorrect since patient advocacy goes beyond clinical procedures to encompass holistic care that addresses the patients' preferences and rights.
A case manager is preparing a discharge plan for a client following coronary artery bypass grafting surgery. Which of the following client issues should the nurse address first?
- A. Inadequate food supply
- B. Low pain tolerance
- C. Limited social support
- D. Decreased self-esteem
Correct Answer: A
Rationale: The nurse should address the inadequate food supply first as it directly impacts the client's health post-discharge. Proper nutrition is crucial for recovery after surgery, especially such as coronary artery bypass grafting. While low pain tolerance, limited social support, and decreased self-esteem are all important issues to address, addressing the client's nutritional needs is the priority in this scenario to ensure optimal recovery and healing.
Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?
- A. The client will be very thirsty.
- B. The client will complain of nausea.
- C. The client will need to urinate.
- D. The client will have moist skin.
Correct Answer: D
Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.
What is the normal sodium level in the body?
- A. 135 to 145 milliequivalents per liter.
- B. 3 to 5 milliequivalents per liter.
- C. 135 to 145 microequivalents per liter.
- D. 3 to 5 microequivalents per liter.
Correct Answer: A
Rationale: The correct answer is A: 135 to 145 milliequivalents per liter. The normal range for sodium levels in the body is expressed in milliequivalents per liter, not microequivalents. Choice B and D provide a significantly lower range which is not within the normal values for sodium. Choice C incorrectly states 'microequivalents' instead of the correct unit 'milliequivalents'. Therefore, A is the correct answer.