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A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication?
- A. I had strep throat about one year ago.
- B. I got my flu shot at the pharmacy two weeks ago.
- C. I plan to continue nursing my baby until he is at least a year old.
- D. I am allergic to shellfish.
Correct Answer: C
Rationale: The correct answer is C. Glyburide is not recommended for use during breastfeeding as it can pass into breast milk and potentially harm the baby. Breastfeeding mothers should consult their healthcare provider for alternative medications. Choice A is unrelated, choice B and D are not contraindications for glyburide use.
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A nurse is planning client care for herself and an assistive personnel (AP) working with her. Which of the following tasks should the nurse plan to perform?
- A. Assisting a client to cough and deep breathe
- B. Application of antiembolic stockings
- C. Administration of an enema
- D. Assessing a client's sacrum for edema
Correct Answer: D
Rationale: The correct answer is D. The nurse should plan to perform the task of assessing a client's sacrum for edema. This task requires critical thinking and nursing judgment to assess for potential complications such as pressure ulcers. Nurses are trained to assess and identify abnormalities in a client's condition.
Choice A: Assisting a client to cough and deep breathe can be delegated to the AP as it is within their scope of practice.
Choice B: Application of antiembolic stockings is a task that can be safely delegated to the AP as it is a routine procedure that does not require nursing assessment.
Choice C: Administration of an enema is a task that can be delegated to the AP as it is a routine procedure that does not require nursing assessment.
A client who is terminally ill tells a nurse on the medical-surgical unit that she feels hopeless. Which of the following statements by the nurse is appropriate?
- A. I am sure these feelings will pass once you go home.
- B. Tell me what you understand about your illness.
- C. Tell me why you feel hopeless.
- D. If I were you, I would ask for a referral to hospice care.
Correct Answer: B
Rationale: The correct answer is B: "Tell me what you understand about your illness." This response shows active listening and encourages the client to express their thoughts and feelings, fostering trust and understanding. It allows the nurse to assess the client's knowledge and perception, helping tailor support accordingly. Choice A dismisses the client's feelings, lacking empathy. Choice C may come off as confrontational, potentially shutting down communication. Choice D imposes the nurse's opinion on the client. Choices E, F, and G are not applicable. In summary, choice B promotes therapeutic communication and client-centered care, while the other choices may hinder the nurse-client relationship.
A nurse is supervising a newly licensed nurse who is caring for a client on a behavioral health unit. Complete the following sentence by using the list of options.
- A. provide continuous monitoring of this client
- B. assess for readiness for release from seclusion
- C. clearly document reason for seclusion then obtain provider prescription for seclusion or restraints
- D. provide means for hygiene and elimination
- E. discuss reason for seclusion with client
- F. offer food and fluids
Correct Answer: A,C
Rationale: The correct answers are A and C. A is important to ensure the safety and well-being of the client, especially in a behavioral health unit where close monitoring is crucial. C is necessary to ensure proper documentation and adherence to protocols when seclusion or restraints are used. B is incorrect as assessing readiness for release from seclusion should only be done by a qualified provider. D is important but not as urgent as continuous monitoring. E is not appropriate as discussing the reason for seclusion with the client may not be beneficial during an acute episode. F is important but providing food and fluids should not be the priority over continuous monitoring and proper documentation.
A nurse manager is reviewing incident reports from the past month. Which of the following situations should the nurse prioritize for follow-up?
- A. A client received a meal tray with the wrong diet.
- B. An assistive personnel failed to report a client's low blood glucose level.
- C. A nurse documented a medication administration 30 minutes late.
- D. A client's call light was answered after a 10-minute delay.
Correct Answer: B
Rationale: The correct answer is B. Prioritizing follow-up on the assistive personnel's failure to report a client's low blood glucose level is crucial as it directly impacts patient safety and could lead to serious consequences. Not reporting a critical health issue promptly can result in harm or even death. Addressing this issue promptly is essential to prevent recurrence and ensure the well-being of the patient. Choices A, C, and D involve errors or delays that are concerning but do not pose an immediate threat to patient safety compared to the failure to report a critical health issue.
A home health nurse is planning care for a client who has Alzheimer's disease. The client's partner is her primary caregiver and reports not having enough time to complete his errands. Which of the following referrals should the nurse plan to make?
- A. Respite care
- B. Restorative care
- C. Hospice care
- D. Mental health care
Correct Answer: A
Rationale: The correct answer is A: Respite care. This is the most appropriate referral for the client's partner who needs time off from caregiving responsibilities to complete errands. Respite care provides temporary relief for the primary caregiver, allowing them to take a break while ensuring the client's needs are still met. This helps prevent caregiver burnout and promotes overall well-being for both the caregiver and the client.
Choices B, C, and D are incorrect:
B: Restorative care focuses on restoring the client's functional abilities and independence, which is not directly related to the partner's need for time off.
C: Hospice care is for clients with terminal illnesses who are no longer receiving curative treatment, which is not applicable in this scenario.
D: Mental health care may be beneficial for the client or caregiver in managing emotions and stress, but it does not address the immediate need for respite care.