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A nurse is assessing a client who received an IV fluid bolus for dehydration. Which of the following findings should the nurse identify as an indication of fluid volume excess?
- A. Hypotension
- B. Distended neck veins
- C. Slow capillary refill
- D. Weak, thready pulse
Correct Answer: B
Rationale: The correct answer is B: Distended neck veins. When a client has fluid volume excess, there is an accumulation of fluid in the intravascular space, leading to increased venous pressure. Distended neck veins are a classic sign of fluid overload as they indicate increased central venous pressure. Hypotension (A) is more commonly associated with fluid volume deficit. Slow capillary refill (C) and weak, thready pulse (D) are indicative of poor tissue perfusion, which is more commonly seen in fluid volume deficit rather than excess.
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A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?
- A. Lispro (Humalog)
- B. Glargine (Lantus)
- C. Detemir (Levemir)
- D. NPH (Humulin N)
Correct Answer: A
Rationale: The correct answer is A: Lispro (Humalog). Lispro is a rapid-acting insulin that is ideal for mealtime coverage in intensive insulin therapy because it mimics the body's natural insulin response after a meal, providing quick and effective blood sugar control. Lispro has a rapid onset of action, peaks quickly, and has a shorter duration of action compared to other types of insulin. This makes it suitable for covering the rise in blood sugar levels that occurs after meals.
Summary of why other choices are incorrect:
B: Glargine (Lantus) is a long-acting insulin used for basal coverage, not for mealtime coverage.
C: Detemir (Levemir) is an intermediate-acting insulin used for basal coverage, not for mealtime coverage.
D: NPH (Humulin N) is an intermediate-acting insulin with a slower onset and longer duration of action, making it less suitable for mealtime coverage in intensive insulin therapy.
In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?
- A. Ensure sterilization of nondisposable items with ethylene oxide.
- B. Wear hypoallergenic latex gloves that do not contain powder.
- C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
- D. Wrap monitoring cords with stockinette and tape them in place.
Correct Answer: B
Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. This is the best precaution because it minimizes the risk of the client having an allergic reaction to latex during the procedure. Powdered latex gloves can release latex particles into the air, increasing the likelihood of a reaction. Hypoallergenic gloves are designed to reduce the risk of allergic responses.
Choice A is incorrect as ethylene oxide is used for sterilization of medical equipment, not specifically for latex allergy precautions. Choice C is incorrect because cleansing latex ports with chlorhexidine does not address the risk of latex exposure. Choice D is also incorrect as wrapping monitoring cords does not directly address the issue of latex allergy.
After correcting the IVF infusion rate, what should be the next step in the client's care?
- A. Notify family
- B. Discipline the previous nurse
- C. Complete an incident report
- D. Obtain legal consultation
Correct Answer: C
Rationale: The correct answer is C: Complete an incident report. This is the next step to document the error and ensure proper follow-up. It helps in analyzing the root cause, implementing preventive measures, and ensures transparency in patient care. Notifying the family (A) can wait until the situation is under control. Disciplining the previous nurse (B) should not be the immediate focus and may come after a thorough investigation. Obtaining legal consultation (D) is premature and should only be considered if the incident escalates to a legal issue.
Achieving Magnet Hospital designation offers hospitals the following advantages: (Select all that apply.)
- A. Greater client satisfaction.
- B. Improved nursing recruitment.
- C. Greater client workload.
- D. Nurses who are independent decision makers.
Correct Answer: C
Rationale: The correct answer is C: Greater client workload. Magnet Hospitals are known for their commitment to nursing excellence, which leads to improved patient outcomes and increased demand for their services. This higher demand can result in a greater client workload for the hospital. The other choices are incorrect because A (Greater client satisfaction) and B (Improved nursing recruitment) are potential benefits of Magnet Hospital designation, but they are not guaranteed advantages. Choice D (Nurses who are independent decision makers) is not directly related to the advantages of achieving Magnet Hospital designation. Therefore, the correct answer is C as it aligns with the core principles of Magnet Hospitals.
The complexities of the current health care delivery systems require a variety of leadership styles. Which of the following leadership styles would be most effective in this environment?
- A. Autocratic leadership
- B. Laissez-faire leadership
- C. Transactional leadership
- D. Transformational leadership
Correct Answer: D
Rationale: The correct answer is D: Transformational leadership. In the current health care environment, transformational leadership is most effective as it focuses on inspiring and motivating individuals to achieve a common goal through innovation and vision. This style encourages creativity, adaptability, and collaboration, which are essential in navigating the complexities of the health care delivery systems. Transformational leaders empower their team members, foster a culture of continuous improvement, and drive positive change. Autocratic leadership (A) is too controlling, Laissez-faire leadership (B) lacks direction and accountability, and Transactional leadership (C) focuses on rewards and punishments rather than inspiring and developing individuals.