Nokea
A client who will undergo neurosurgery the following week tells the nurse in the surgeon's office that he will prepare his advance directives before he goes to the hospital. Which of the following statements by the client indicates to the nurse that he understands advance directives?
- A. I'd rather have my brother make decisions for me, but I know it has to be my wife.
- B. I know they won't go ahead w/the surgery unless I prepare these forms.
- C. I plan to write that I don't want them to keep me on a breathing machine.
- D. I will get my regular doctor to approve my plan before I hand it in at the hospital.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates understanding of advance directives by stating a specific treatment preference, which is not wanting to be kept on a breathing machine. This indicates the client's awareness of the purpose of advance directives in specifying their healthcare wishes.
Choice A is incorrect because it shows a lack of understanding that the client is the one who should make decisions about their care. Choice B is incorrect as it focuses on the surgery proceeding rather than the purpose of advance directives. Choice D is incorrect as it does not show an understanding of the purpose of advance directives but rather a general approval process.
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A nurse is caring for a client who is having difficulty breathing. The client is lying in bed & is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority?
- A. Increase the oxygen flow.
- B. Assist the client to Fowler's position.
- C. Promote removal of pulmonary secretions.
- D. Obtain a specimen for arterial blood gases.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to Fowler's position. This is the priority intervention because elevating the client to Fowler's position helps improve lung expansion and oxygenation by reducing pressure on the diaphragm and allowing better ventilation. Increasing oxygen flow (Choice A) may be needed, but positioning takes precedence. Promoting removal of pulmonary secretions (Choice C) is important but not the priority in this case. Obtaining arterial blood gases (Choice D) is important for assessing oxygenation status but can be done after ensuring optimal positioning.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? Select all.
- A. Apply suction while withdrawing the catheter
- B. Perform suctioning on a routine basis, Q2-3 hours
- C. Maintain medical asepsis during suctioning
- D. Use a new catheter for each suctioning attempt
- E. Limit suctioning to 2-3 attempts
Correct Answer: A, D, E
Rationale: Correct Answer: A, D, E
Rationale:
A: Apply suction while withdrawing the catheter - This guideline ensures effective removal of secretions without damaging the airway.
D: Use a new catheter for each suctioning attempt - Reusing catheters can introduce infection and compromise patient safety.
E: Limit suctioning to 2-3 attempts - Excessive suctioning can lead to hypoxia and damage to the airway. Limiting attempts is safer for the patient.
Incorrect Choices:
B: Performing suctioning on a routine basis, Q2-3 hours can be harmful as it may lead to unnecessary trauma to the airway and increased risk of infection.
C: Maintaining medical asepsis during suctioning is a general guideline but not specific to endotracheal suctioning.
A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? Select all.
- A. Restlessness
- B. Tachypnea
- C. Bradycardia
- D. Confusion
- E. Pallor
Correct Answer: A,B,E
Rationale: Correct Answer: A, B, E
Rationale:
1. Restlessness: Early sign of hypoxemia due to the body's attempt to increase oxygen intake.
2. Tachypnea: Increased respiratory rate compensates for low oxygen levels in the blood.
3. Pallor: Skin paleness indicates poor oxygenation of tissues due to hypoxemia.
Incorrect Choices:
C: Bradycardia - Bradycardia is a late sign of hypoxemia, not an early indication.
D: Confusion - Confusion is a late sign of severe hypoxemia affecting the brain function.
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation?
- A. "Right client"
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. The 5 rights of delegation are essential for safe and effective delegation. Right supervision/evaluation ensures appropriate oversight, feedback, and accountability. Right direction/communication emphasizes clear instructions and open communication. Right circumstances consider factors like workload and resources. Right client (choice A) and right time (choice D) are not part of the 5 rights of delegation. In summary, choices A and D are incorrect because they do not align with the established principles of delegation, while choices B, C, and E are crucial components for successful delegation.
A nursing instructor is reviewing documentation w/a group of nursing students. Which of the following legal guidelines should they follow when documenting a client's record? Select all.
- A. Cover errors w/correction fluid, & write in the correct info
- B. Put the date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of the shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting the date and time on all entries is crucial for accurate documentation, ensuring a clear timeline of events for continuity of care and legal purposes.
C: Documenting objective data without opinions maintains professionalism and accuracy, preventing subjective biases from affecting the client's record.
Incorrect Choices:
A: Covering errors with correction fluid can be seen as tampering with records, potentially leading to legal issues and compromising the integrity of the documentation.
D: Using excessive abbreviations can lead to misinterpretations and errors in communication, jeopardizing patient safety and legal clarity.
E: Waiting until the end of the shift to document can result in information being missed or forgotten, impacting the quality of care and legal accountability.