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A nurse is planning strategies to manage time effectively for client care. Which of the following strategies should the nurse implement?
- A. Combine client care tasks when caring for multiple clients.
- B. Wait until the end of the shift to document client care.
- C. Use the planning step of the nursing process to prioritize client care delivery.
- D. Allow for interruptions in tasks to discuss client care issues with colleagues.
Correct Answer: C
Rationale: Correct Answer: C - Use the planning step of the nursing process to prioritize client care delivery.
Rationale:
1. The planning step involves setting goals, outcomes, and interventions, helping the nurse organize and prioritize care efficiently.
2. Prioritizing care based on client needs ensures critical tasks are addressed first, promoting client safety and well-being.
3. It allows the nurse to allocate time effectively, focusing on urgent and important tasks first.
4. By following the nursing process, the nurse can provide individualized care tailored to each client's specific needs.
Incorrect Choices:
A: Combining tasks can lead to overlooking important details for each client.
B: Waiting to document care can result in errors, omissions, and delays in communication.
D: Allowing interruptions can disrupt workflow and hinder efficient time management.
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A nurse is caring for 3 clients who have COPD. Select the 3 findings that require follow-up. Nurses' Notes: Temperature 100°F, oxygen saturation 88%, blood pressure 130/80 mmHg. Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in the left upper lobe and decreased breath sounds at bases bilaterally. Heart rate 98 beats/min.
- A. Temperature 100°F
- B. Oxygen saturation 88%
- C. Blood pressure 130/80 mmHg
- D. Heart rate 98 beats/min
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A temperature of 100°F indicates possible infection or inflammation, warranting follow-up. An oxygen saturation of 88% is below the normal range, indicating hypoxemia. A heart rate of 98 beats/min is elevated, suggesting increased work of breathing or stress on the cardiovascular system. Choice C, blood pressure of 130/80 mmHg, falls within the normal range and does not require immediate follow-up. Choices E, F, and G are not relevant findings in this scenario.
A nurse is admitting a client to a healthcare facility. The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct answers are A, B, C, and E.
A: Wearing an N95 mask is crucial to prevent the spread of airborne infections.
B: Placing a container for soiled linens inside the room prevents contamination of other areas.
C: Placing the client in a negative airflow room helps contain infectious particles.
E: Wearing a gown within 3 feet of the client prevents exposure to bodily fluids.
D: Removing the mask after exiting the room increases the risk of contamination.
False options would include not utilizing an N95 mask, not isolating soiled linens, not placing the client in a negative airflow room, and not wearing appropriate PPE when close to the client.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
- A. A lesion with uniform pigmentation
- B. New appearance of petechiae
- C. A mole with an asymmetrical appearance
- D. The presence of a papule
Correct Answer: C
Rationale: The correct answer is C: A mole with an asymmetrical appearance. This is indicative of a potential skin malignancy such as melanoma. The asymmetry suggests irregular growth patterns, which can be a sign of cancerous cells. Other choices, such as A (lesion with uniform pigmentation), B (petechiae), and D (presence of a papule) are not specific indicators of skin malignancy. Lesions with uniform pigmentation are more likely to be benign. Petechiae are tiny red spots due to bleeding under the skin and are not typically associated with skin cancer. Papules are small raised bumps that can have various causes, not necessarily cancerous. Therefore, choice C is the most concerning finding for skin cancer based on asymmetry, prompting further evaluation and possible biopsy.
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 caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury to the client?
- A. Use a bed exit alarm system.
- B. Raise four side rails while the client is in bed.
- C. Apply one soft wrist restraint.
- D. Dim the lights in the client's room.
Correct Answer: A
Rationale: The correct answer is A: Use a bed exit alarm system. This intervention is crucial in minimizing the risk of injury for a client with dementia as it alerts the nurse when the client attempts to get out of bed, preventing falls. This approach promotes client safety by allowing timely intervention. Raising four side rails (B) may restrict the client's movement and cause agitation or attempts to climb over the rails, increasing the risk of injury. Applying a soft wrist restraint (C) is considered a restrictive measure and should be avoided unless absolutely necessary due to the risk of causing emotional distress and physical harm to the client. Dimming the lights (D) in the client's room may increase confusion and disorientation, leading to a higher risk of falls.