Nokea
A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is:
- A. Measure intake and output
- B. Check albumin level
- C. Monitor glucose levels
- D. Increase enteral feeding
Correct Answer: A
Rationale: Measuring intake and output assesses fluid balance, critical in enteral feeding to prevent dehydration or fluid overload due to hyperosmotic feedings.
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A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
- A. shopping for groceries
- B. house cleaning
- C. transportation to physician's visits
- D. medication instruction
Correct Answer: D
Rationale: The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and transportation services are all examples of unskilled services offered by volunteer and fee-for-service agencies.
The client is undergoing a 24-hour urine specimen collection. Twenty hours into the collection period, a single voided urine is accidentally discarded. What is the nurse's best action?
- A. Resume the urine collection and collect one additional voided specimen.
- B. Discard the urine collected and begin a new urine collection immediately.
- C. Complete the urine collection and send all urine collected to the laboratory.
- D. Dispose of the urine collected and reschedule the test to begin the next morning.
Correct Answer: B
Rationale: B: A discarded void invalidates the collection; restarting ensures accuracy. A: Adding a void causes inaccuracies. C: Missing a void compromises results. D: Rescheduling is unnecessary as the test can start anytime.
All of the following are common reasons that nurses are reluctant to delegate except:
- A. lack of self-confidence.
- B. desire to maintain authority.
- C. confidence in subordinates.
- D. getting trapped in the 'I can do it better myself' mindset.
Correct Answer: C
Rationale: If a delegator has confidence in his subordinates and feels that a task will be performed correctly, he is more likely to delegate. Reasons that delegators are reluctant to delegate include their own lack of confidence, fear of losing authority or personal satisfaction, and feeling that the task can only be performed correctly if they do it themselves.
A hospital discharge planning nurse is making arrangements for a client who has an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
- A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters
- B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital
- C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility
Correct Answer: B
Rationale: Transferring to a facility unprepared for epidural catheter management risks client safety. Finding a capable facility ensures continuity of care.
Client room environments should include:
- A. a made bed, fresh water, thermostat regulation, and clean floors in all occupied client areas.
- B. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
- C. accident prevention, comfort, a room (including furniture) that has been cleaned with chloroseptic wash, a bed that is made every other day.
- D. odor control (by spraying the room with deodorizers), closet storage of all client objects, a clean room. (Gloves should be worn when cleaning.)
- E. a made bed, comfort and safety, a clutter-free area, hygiene articles nearby.
Correct Answer: B
Rationale: Preparing a client's room environment should include making the client's bed, ensuring comfort and safety at all times, keeping the area free of clutter, and keeping the client's hygiene articles nearby. All procedures should be explained before they are performed, and the client should assist with personal arrangement of articles.