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A nurse is caring for a client who has a nasogastric (NG) tube and is receiving intermittent
feedings through an open system. Which of the following actions should the nurse take first?
- A. Make sure the enteral formula is at room temperature.
- B. Wipe the top of the formula can with alcohol.
- C. Rinse the feeding bag with water between feedings.
- D. Tell the client to keep the head of the bed elevated at least 30°
Correct Answer: B
Rationale: The correct answer is B: Wipe the top of the formula can with alcohol. This is the first action the nurse should take because it ensures the cleanliness and sterility of the formula before administering it to the client through the NG tube, reducing the risk of contamination and infection.
A: Making sure the enteral formula is at room temperature is important but not the first action to take.
C: Rinsing the feeding bag with water between feedings is not necessary for every feeding and does not address the immediate need to ensure the cleanliness of the formula.
D: Instructing the client to keep the head of the bed elevated is important for preventing aspiration but is not the first action to take in this scenario.
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A Nurse Manager completes an interruption log and identifies two staff members who take an inordinate amount of time with drop-in issues that are not urgent. What are some methods to address this behavior in an attempt to better manage time? (Select all that apply.)
- A. Designate specific time slots for drop-in visits.
- B. Position the desk chair so it is not facing the hallway.
- C. Communicate with staff about using e-mail for non-urgent matters to improve time management.
- D. When staff members drop in, the manager should stand and remain standing during the conversation.
Correct Answer: A
Rationale: Correct Answer: A: Designate specific time slots for drop-in visits.
Rationale:
1. Designating specific time slots for drop-in visits allows for better time management by setting boundaries and expectations.
2. It helps staff members plan their interactions with the Nurse Manager, reducing interruptions throughout the day.
3. This method promotes efficiency and productivity by consolidating similar tasks into designated blocks of time.
Summary of other choices:
B: Position the desk chair so it is not facing the hallway - This may help reduce distractions but does not directly address time management.
C: Communicate with staff about using e-mail for non-urgent matters to improve time management - While this is a good practice, it does not specifically address the issue of inordinate time spent on drop-in visits.
D: When staff members drop in, the manager should stand and remain standing during the conversation - Standing may convey urgency, but it does not provide a structured approach to managing time effectively.
When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
- A. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.
- B. Discuss the reason for the use of insulin therapy during the immediate postoperative period.
- C. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
- D. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.
Correct Answer: C
Rationale: The correct answer is C: Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
Rationale:
1. Administering insulin falls under the scope of practice for an LPN/LVN.
2. Administering lispro insulin before surgery helps maintain the patient's blood glucose within a safe range during the procedure.
3. LPN/LVNs are trained to administer medications safely and accurately.
Summary:
A: Communication with the circulating nurse requires critical thinking and interpretation, which may be beyond the scope of an LPN/LVN.
B: Discussing the reason for insulin therapy involves patient education and interpretation, which are typically responsibilities of a registered nurse.
D: Planning strategies to prevent hypoglycemia or hyperglycemia requires higher-level critical thinking and assessment skills, usually performed by a registered nurse.
Which of the following statements about time management is true?
- A. Time management is not important in nursing
- B. Writing goals will increase stress
- C. Effective time management reduces stress
- D. Setting goals is a time waster
Correct Answer: C
Rationale: The correct answer is C: Effective time management reduces stress. This is because when you manage your time well, you are able to prioritize tasks, allocate sufficient time for each activity, and avoid feeling overwhelmed. By having a clear plan and schedule, you can reduce stress levels and increase productivity.
Now, let's analyze why the other choices are incorrect:
A: Time management is not important in nursing - This is incorrect because time management is crucial in nursing to ensure patient care is delivered efficiently.
B: Writing goals will increase stress - This is incorrect as setting goals helps in providing direction and motivation, reducing stress in the long run.
D: Setting goals is a time waster - This is incorrect because setting goals helps in defining objectives and tracking progress, which is essential for effective time management.
Which of the following is an example of a tertiary prevention strategy?
- A. Administering childhood vaccinations
- B. Chemotherapy for cancer treatment
- C. Routine screening for hypertension
- D. Physical therapy for stroke rehabilitation
Correct Answer: D
Rationale: The correct answer is D: Physical therapy for stroke rehabilitation. Tertiary prevention focuses on minimizing the impact of an existing disease or condition. Physical therapy for stroke rehabilitation is an example of tertiary prevention because it aims to improve the quality of life and functionality of an individual who has already experienced a stroke. Administering childhood vaccinations (A) is an example of primary prevention to prevent the onset of diseases. Chemotherapy for cancer treatment (B) is an example of secondary prevention to detect and treat existing cancer. Routine screening for hypertension (C) is an example of secondary prevention to identify and manage hypertension before it progresses.
Which finding indicates a need to contact the health care provider before the nurse
administers metformin (Glucophage)?
- A. The patient’s blood glucose level is 174 mg/dL.
- B. The patient has gained 2 lb (0.9 kg) since yesterday.
- C. The patient is scheduled for a chest x-ray in an hour
- D. The patient’s blood urea nitrogen (BUN) level is 52 mg/dL.
Correct Answer: D
Rationale: The correct answer is D because an elevated BUN level of 52 mg/dL indicates potential kidney dysfunction, which is a contraindication for metformin due to the risk of lactic acidosis.
A: Blood glucose level of 174 mg/dL is slightly high but not a contraindication for metformin.
B: Weight gain is unrelated to metformin administration.
C: Chest x-ray does not directly impact metformin administration.