Nokea
A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?
- A. Blood glucose level
- B. Serum sodium level
- C. Serum calcium level
- D. Blood urea nitrogen (BUN)
Correct Answer: A
Rationale: The correct answer is A: Blood glucose level. The healthcare professional should check the blood glucose level first because hypoglycemia or hyperglycemia can cause confusion. Hypoglycemia can lead to altered mental status quickly and should be ruled out immediately. Checking the serum sodium level (B), serum calcium level (C), or blood urea nitrogen (D) can be important in further assessment, but addressing the blood glucose level is the primary concern in this scenario to rule out any immediate life-threatening conditions related to glucose imbalance.
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At what point should a 24-year-old client without a family history of eye disease have an eye exam?
- A. Annually after the age of 30
- B. Initially, a thorough exam at the age of 40
- C. Initially, a thorough exam at the age of 50
- D. Annually after the age of 50
Correct Answer: B
Rationale: For individuals without risk factors, a baseline eye exam is recommended at age 40 to detect early signs of age-related conditions.
Which setting allows the dying client to have advanced care in an institution due to the necessity to control pain unable to be managed at home?
- A. Hospice care
- B. Acute care
- C. Palliative care
- D. Home care
Correct Answer: C
Rationale: Palliative care specializes in managing complex symptoms and pain, providing advanced institutional support.
What are the priority nursing interventions for a client in shock?
- A. Hypoxia
- B. Hypercapnia
- C. Acidosis
- D. Alkalosis
Correct Answer: C
Rationale: Acidosis occurs when blood pH drops below 7.35 due to an accumulation of hydrogen ions, commonly resulting from respiratory or metabolic imbalances.
A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
- A. Determining if the UAP knew how to take blood pressure
- B. Double-checking the UAP by taking another blood pressure
- C. Providing more appropriate supervision of the UAP
- D. Taking the blood pressure instead of delegating the task
Correct Answer: C
Rationale: The correct answer is C: Providing more appropriate supervision of the UAP. By providing adequate supervision, the nurse can ensure that the UAP is performing tasks correctly and can intervene if any issues arise. This would have likely prevented the negative outcome as the nurse could have identified the high blood pressure and changed mental status earlier.
A: Determining if the UAP knew how to take blood pressure - While assessing the UAP's competence is important, it does not address the need for ongoing supervision and oversight.
B: Double-checking the UAP by taking another blood pressure - This approach does not address the root cause of the issue, which is the lack of appropriate supervision.
D: Taking the blood pressure instead of delegating the task - This is not a sustainable solution as delegating tasks to UAPs is a common practice in healthcare settings. Providing appropriate supervision is key to ensuring safe and effective delegation.
A healthcare professional is interested in making interdisciplinary work a high priority. Which actions by the professional best demonstrate this skill? (Select ONE that does not apply)
- A. Consulting with other disciplines on client care
- B. Coordinating discharge planning for home safety
- C. Participating in comprehensive client rounding
- D. Sharing the care plans with other disciplines
Correct Answer: B
Rationale: The correct answer is B because coordinating discharge planning for home safety is not directly related to interdisciplinary work. The other choices (A, C, D) involve active collaboration and communication with different disciplines to ensure comprehensive client care. Consulting with other disciplines, participating in client rounding, and sharing care plans all demonstrate a high priority on interdisciplinary work by fostering teamwork and integration of various perspectives to enhance patient outcomes. In contrast, coordinating discharge planning for home safety is more focused on individual patient needs and safety rather than interdisciplinary collaboration.