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A client experiences difficulty breathing after the change of shift. The nurse on duty discovers that the IVFs were infusing at a rate 10 times the calculated normal. After notifying the physician and correcting the 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 in the client's care because documenting the incident is crucial for quality improvement and patient safety. It helps identify the root cause, prevent future errors, and ensure accountability. Notifying the family (A) may be necessary but not the immediate next step. Disciplining the previous nurse (B) is not appropriate without a thorough investigation. Obtaining legal consultation (D) may be needed later but is not the immediate priority.
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When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
- A. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.
- B. Discuss the reason for the use of insulin therapy during the immediate postoperative period.
- C. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
- D. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.
Correct Answer: C
Rationale: The correct answer is C: Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
Rationale:
1. Administering insulin falls under the scope of practice for an LPN/LVN.
2. Administering lispro insulin before surgery helps maintain the patient's blood glucose within a safe range during the procedure.
3. LPN/LVNs are trained to administer medications safely and accurately.
Summary:
A: Communication with the circulating nurse requires critical thinking and interpretation, which may be beyond the scope of an LPN/LVN.
B: Discussing the reason for insulin therapy involves patient education and interpretation, which are typically responsibilities of a registered nurse.
D: Planning strategies to prevent hypoglycemia or hyperglycemia requires higher-level critical thinking and assessment skills, usually performed by a registered nurse.
Nurse Managers work with staff to educate them about ways to diffuse potentially violent situations. Which of the following diagnoses can staff expect to be more frequently associated with violence?
- A. Alcohol or drug withdrawal
- B. Anxiety
- C. Depression
- D. Confusion
Correct Answer: A
Rationale: The correct answer is A: Alcohol or drug withdrawal. This is because individuals experiencing withdrawal from alcohol or drugs may exhibit aggressive behavior due to physical and psychological effects of withdrawal. This can lead to volatile and potentially violent situations.
Choice B: Anxiety, and choice C: Depression, are less likely to be directly associated with violent behavior compared to withdrawal symptoms.
Choice D: Confusion, while it can lead to misunderstandings or agitation, is not as consistently linked to violent behavior as alcohol or drug withdrawal.
Therefore, staff should be more prepared to manage and diffuse potentially violent situations when dealing with individuals experiencing alcohol or drug withdrawal.
A Nurse Manager completes an interruption log and identifies two staff members who take an inordinate amount of time with drop-in issues that are not urgent. What are some methods to address this behavior in an attempt to better manage time? (Select all that apply.)
- A. Designate specific time slots for drop-in visits.
- B. Position the desk chair so it is not facing the hallway.
- C. Communicate with staff about using e-mail for non-urgent matters to improve time management.
- D. When staff members drop in, the manager should stand and remain standing during the conversation.
Correct Answer: A
Rationale: Correct Answer: A: Designate specific time slots for drop-in visits.
Rationale:
1. Designating specific time slots for drop-in visits allows for better time management by setting boundaries and expectations.
2. It helps staff members plan their interactions with the Nurse Manager, reducing interruptions throughout the day.
3. This method promotes efficiency and productivity by consolidating similar tasks into designated blocks of time.
Summary of other choices:
B: Position the desk chair so it is not facing the hallway - This may help reduce distractions but does not directly address time management.
C: Communicate with staff about using e-mail for non-urgent matters to improve time management - While this is a good practice, it does not specifically address the issue of inordinate time spent on drop-in visits.
D: When staff members drop in, the manager should stand and remain standing during the conversation - Standing may convey urgency, but it does not provide a structured approach to managing time effectively.
The type of theory that discusses how motivation works to direct a person's efforts is:
- A. Reinforcement.
- B. Operant.
- C. Conditioning.
- D. Process.
Correct Answer: D
Rationale: The correct answer is D: Process. Process theories of motivation focus on how individuals initiate, sustain, and direct their behavior towards achieving goals. These theories explore the cognitive processes involved in motivation, such as goal-setting, expectancy, and self-regulation. They highlight the importance of understanding individuals' thought processes and decision-making in driving their efforts.
Rationale:
A: Reinforcement theories primarily focus on how behavior is influenced by consequences, such as rewards and punishments. While reinforcement is a factor in motivation, it does not address the cognitive processes underlying motivation.
B: Operant theories, like reinforcement, concentrate on how behavior is shaped by consequences. However, they do not delve into the internal cognitive processes that drive motivation.
C: Conditioning theories, such as classical and operant conditioning, emphasize how behavior is learned through associations and reinforcements. While conditioning plays a role in shaping behavior, it does not directly address how motivation works to direct efforts based on cognitive processes.
In summary, the correct answer, D
The nurse manager is responsible for implementing a new electronic health record (EHR) system. What is the first step in this process?
- A. Train all staff on the new system
- B. Identify the project team
- C. Develop a training program
- D. Conduct a needs assessment
Correct Answer: B
Rationale: The correct answer is B: Identify the project team. This is the first step in implementing a new EHR system as it involves selecting individuals with the necessary skills and expertise to oversee the project. Once the project team is in place, they can then move on to conducting a needs assessment (D) to identify requirements, developing a training program (C) based on the assessment, and finally training all staff on the new system (A) with the guidance of the project team. Identifying the project team first ensures there is leadership and direction in place to effectively carry out the implementation process.