Nokea
A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
- A. Remove the restraints from the client's wrists
- B. Review the chart for nonrestraint alternatives for agitation
- C. Speak with the AP about the incident
- D. Inform the unit manager of the incident
Correct Answer: A
Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.
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Serge, who has diabetes mellitus, is taking oral agents and is scheduled for a diagnostic test that requires him to be NPO. What is the best plan of action for the nurse regarding Serge's oral medications?
- A. Administer the oral agents immediately after the test.
- B. Notify the diagnostic department and request orders.
- C. Notify the physician and request orders.
- D. Administer the oral agents with a sip of water before the test.
Correct Answer: C
Rationale: The best plan of action for the nurse is to notify the physician and request orders regarding Serge's oral medications. By involving the physician, the nurse ensures that appropriate instructions are obtained, considering Serge's medical condition and the need for NPO status for the diagnostic test. Administering the medications without medical guidance (choice A) can be risky, as it may affect the test results. Notifying the diagnostic department (choice B) is not the most direct and appropriate action; the physician is the primary healthcare provider responsible for medication orders. Administering the medications with water before the test (choice D) is not advisable when the patient is supposed to be NPO, as it can interfere with the test requirements.
A nurse reviews a client's laboratory report and notes that the client's serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?
- A. Alcoholism
- B. Renal insufficiency
- C. Hypoparathyroidism
- D. Tumor lysis syndrome
Correct Answer: A
Rationale: The correct answer is A: Alcoholism. Alcoholism can lead to hypophosphatemia due to poor dietary intake and other factors. Excessive alcohol consumption can result in malnutrition, particularly a deficiency in phosphorus. Choices B, C, and D are unlikely to cause low serum phosphorus levels. Renal insufficiency is more likely to cause hyperphosphatemia, hypoparathyroidism is associated with hypocalcemia rather than hypophosphatemia, and tumor lysis syndrome typically presents with hyperphosphatemia due to the release of intracellular phosphate.
A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. You should contact the provider about your wishes for your family member.
- B. We'll need to have the nursing supervisor review the client's advance directives.
- C. You should speak with the facility's ethics committee about your concerns.
- D. As the health care surrogate, the client's partner can make this decision.
Correct Answer: D
Rationale: The correct response is D because the health care surrogate, as designated by the client, has the legal authority to make healthcare decisions on behalf of the client when they are unable to do so. This authority includes decisions about treatment continuation or withdrawal. Option A is incorrect as the family member's wishes do not override the legal authority of the health care surrogate. Option B is not the most appropriate action in this situation as the advance directives are already clear by the designation of a health care surrogate. Option C is not necessary at this stage since the health care surrogate can make the decision without involving the ethics committee.
Which of the following is the best way to improve nursing's image?
- A. Uniforms should reflect your professionalism.
- B. Introduce yourself with your full name.
- C. Understand the essence of professional behavior in your practice.
- D. Take every opportunity to speak to the public about nursing.
Correct Answer: D
Rationale: The correct answer is D because taking every chance to engage with the public about nursing allows for the improvement of nursing's image and the promotion of the profession. Choice A is incorrect as uniforms should reflect professionalism rather than personality. Choice B is not directly related to improving nursing's image. Choice C, while important, does not directly address improving the image of nursing through public engagement.
A clinical instructor teaches a class for the public about diabetes mellitus. Which individual does the nurse assess as being at highest risk for developing diabetes?
- A. The 50-year-old client who does not engage in any physical exercise
- B. The 56-year-old client who drinks three glasses of wine daily
- C. The 42-year-old client who is 50 pounds overweight
- D. The 38-year-old client who smokes one pack of cigarettes daily
Correct Answer: C
Rationale: The 42-year-old client who is 50 pounds overweight is at the highest risk for developing diabetes. Excess weight is a significant risk factor for diabetes as it can lead to insulin resistance and metabolic abnormalities. Choices A, B, and D are also risk factors for diabetes, but being overweight has a stronger association with the development of the condition compared to lack of exercise, excessive alcohol consumption, or smoking.