Nokea
A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?
- A. Explain that all staff are doing their best
- B. Ask for a description of what happened during the night
- C. Tell the daughter to talk to the unit's nurse manager
- D. Reassure the daughter that the mother will get better care
Correct Answer: B
Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.
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The client with a new diagnosis of type 2 diabetes is being taught about diet management by the nurse. Which statement by the client indicates effective learning?
- A. I should not avoid all carbohydrates
- B. I can eat whatever I want as long as I take my medication
- C. I need to eat regular meals and snacks to maintain my blood sugar levels
- D. I will decrease my intake of sugary foods to prevent low blood sugar
Correct Answer: C
Rationale: Choice C is the correct answer because eating regular meals and snacks is crucial for maintaining stable blood sugar levels in individuals with diabetes. This approach helps prevent spikes and drops in blood sugar, promoting better management of the condition. Choices A, B, and D are incorrect. Avoiding all carbohydrates is not recommended as they are a major energy source and can be part of a balanced diet; eating whatever one wants while relying solely on medication can lead to uncontrolled blood sugar levels and complications; decreasing sugary foods intake can actually contribute to high blood sugar levels rather than preventing low blood sugar.
The client is diagnosed with pneumonia. Which intervention is most effective in promoting airway clearance?
- A. Administer bronchodilators as prescribed
- B. Encourage increased fluid intake
- C. Perform chest physiotherapy
- D. Provide humidified oxygen
Correct Answer: B
Rationale: Encouraging increased fluid intake is the most effective intervention in promoting airway clearance for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making it easier for the client to clear the airways. Administering bronchodilators may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy may be beneficial but is not the first-line intervention for promoting airway clearance in pneumonia. Providing humidified oxygen can improve oxygenation but does not directly address airway clearance.
Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?
- A. Assess the client's hemoglobin levels to determine if the client is in shock
- B. Call the surgeon and prepare to take the client back to the operating room
- C. Outline the area with ink and check it every 15 minutes to monitor for changes in bleeding
- D. No action is required as postoperative bleeding can be expected
Correct Answer: C
Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.
A client with hypothyroidism is taking levothyroxine (Synthroid). Which symptom should prompt the nurse to notify the healthcare provider?
- A. Weight gain
- B. Bradycardia
- C. Nervousness and tremors
- D. Fatigue
Correct Answer: C
Rationale: The correct answer is C: Nervousness and tremors. These symptoms may indicate hyperthyroidism resulting from excessive dosing of levothyroxine. Weight gain (Choice A) is a common symptom of hypothyroidism and may indicate undertreatment or inadequate dosing. Bradycardia (Choice B) is a symptom of hypothyroidism and may improve with levothyroxine therapy; it does not typically indicate an urgent need for healthcare provider notification. Fatigue (Choice D) is a symptom of hypothyroidism and can persist even with levothyroxine treatment, so it is not a symptom that would require immediate notification of the healthcare provider.
A client with a diagnosis of hypothyroidism is prescribed levothyroxine (Synthroid). Which symptom should prompt the nurse to notify the healthcare provider?
- A. Weight gain.
- B. Bradycardia.
- C. Nervousness and tremors.
- D. Fatigue.
Correct Answer: C
Rationale: The correct answer is C: 'Nervousness and tremors.' In a client with hypothyroidism prescribed levothyroxine, the development of nervousness and tremors may indicate hyperthyroidism, which can result from excessive dosing of levothyroxine. Therefore, the nurse should promptly notify the healthcare provider to adjust the medication dosage. Choices A, B, and D are incorrect because weight gain, bradycardia, and fatigue are more commonly associated with hypothyroidism itself, indicating that the levothyroxine therapy may not be effective enough, rather than being signs of excessive dosing.