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A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour. Which of the following actions should the nurse take next?
- A. Document the surgeon's instructions in the client's medical record.
- B. Complete an incident report.
- C. Consult the charge nurse.
- D. Notify the nursing manager.
Correct Answer: D
Rationale: The correct answer is D: Notify the nursing manager. The nurse should escalate the situation to the nursing manager because the surgeon's instructions may not be appropriate for a client in hemorrhagic shock. The nurse needs to advocate for the client's safety and ensure prompt and appropriate intervention. Consulting the charge nurse may not be sufficient, and documenting the instructions or completing an incident report does not address the immediate need for proper medical intervention.
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What is the primary purpose of clinical pathways in healthcare?
- A. Reduce hospital readmissions
- B. Standardize care
- C. Provide individualized care
- D. Streamline care processes
Correct Answer: C
Rationale: The correct answer is C: Provide individualized care. Clinical pathways aim to offer a structured approach to patient care while allowing customization based on individual patient needs. By providing a standardized outline of care steps, healthcare providers can tailor treatment plans to meet each patient's unique circumstances. This promotes more personalized and effective care delivery.
Incorrect choices:
A: Reduce hospital readmissions - Clinical pathways may help in reducing readmissions, but this is not their primary purpose.
B: Standardize care - While clinical pathways do standardize care to some extent, their main goal is to individualize care based on patient needs.
D: Streamline care processes - While clinical pathways can streamline care processes, the primary focus is on providing individualized care rather than solely on process efficiency.
What is the focus of a continuous quality improvement program?
- A. Family
- B. Client
- C. Nurse
- D. Physician
Correct Answer: B
Rationale: The correct answer is B: Client. In a continuous quality improvement program, the primary focus should be on improving the quality of care and services provided to the clients or patients. This ensures that their needs and preferences are met, resulting in better outcomes. A focus on the family (A) or healthcare providers like nurses (C) and physicians (D) may be important, but the ultimate goal of a quality improvement program is to enhance the client's experience and well-being. By prioritizing the client, the program can address issues directly affecting them and tailor improvements to meet their specific needs.
When seeking their first nursing job, what is the most important factor that nursing graduates look for?
- A. Location
- B. Money
- C. Orientation
- D. Vacation
Correct Answer: C
Rationale: The correct answer is C: Orientation. Nursing graduates prioritize orientation as the most important factor when seeking their first job because it sets the foundation for their transition into the role. A thorough orientation program provides essential training, support, and guidance, which are crucial for their success and confidence in their new position. Location (A) may be important for convenience, but orientation directly impacts their ability to perform their duties effectively. Money (B) and vacation (D) are important but typically take a back seat to factors that directly impact their ability to excel in their new role.
Which of the following would be considered an urgent and important issue?
- A. Replacing two staff who were injured while caring for a violent patient
- B. Updating the employee break room with new furniture
- C. Preparing educational packets on self-administration of insulin for patients
- D. Arranging a team-building event for staff members
Correct Answer: A
Rationale: The correct answer is A because replacing injured staff dealing with a violent patient is urgent due to staff shortage and important for patient safety. Choice B is not urgent or directly related to patient care. Choice C is important but not urgent. Choice D is important for team morale but not urgent or directly related to patient care.
Which information is most important for the nurse to report to the health care provider before
a patient with type 2 diabetes is prepared for a coronary angiogram?
- A. The patient’s most recent HbA1C was 6.5%
- B. The patient’s admission blood glucose is 128 mg/dL.
- C. The patient took the prescribed metformin (Glucophage) today
- D. The patient took the prescribed captopril (Capoten) this morning.
Correct Answer: C
Rationale: The correct answer is C because metformin is typically held before a coronary angiogram due to the risk of lactic acidosis. This information is crucial for the health care provider to know to prevent potential complications during the procedure. Option A is not as urgent as the patient's current medication status. Option B is less relevant as it does not impact the procedure directly. Option D is important but not as critical as knowing the status of metformin intake. Reporting the patient's current medication, especially metformin, is vital for ensuring patient safety during the coronary angiogram.