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A nurse is assessing a client who had a stroke 2 days ago. Which of the following findings should the nurse identify as a need for a referral to speech-language pathology?
- A. Diminished hand-to-mouth coordination
- B. Impaired voluntary cough
- C. Unilateral ptosis
- D. Altered level of consciousness
Correct Answer: B
Rationale: The correct answer is B: Impaired voluntary cough. Impaired voluntary cough in a client who had a stroke can indicate dysphagia, which is a common complication post-stroke. Referral to speech-language pathology is essential for assessing and managing dysphagia to prevent aspiration pneumonia and malnutrition. Diminished hand-to-mouth coordination (A) may indicate motor deficits but does not directly relate to speech and swallowing. Unilateral ptosis (C) is a drooping eyelid and is not typically a direct concern for speech-language pathology. Altered level of consciousness (D) may indicate neurological issues but does not specifically warrant a referral to speech-language pathology.
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A nurse is caring for a client who is having difficulty walking following a stroke. For which of the following members of the interprofessional team should the nurse request a referral?
- A. Occupational therapist
- B. Social worker
- C. Dietitian
- D. Physical therapist
Correct Answer: D
Rationale: The correct answer is D: Physical therapist. The physical therapist specializes in helping individuals regain mobility and strength after a stroke, making them the most appropriate professional to address the client's difficulty walking. They will develop a personalized exercise program to improve balance and coordination. Referring to the other options would not directly address the client's physical mobility issues. Occupational therapists focus on daily living activities, social workers on emotional and social support, and dietitians on nutritional needs, none of which directly address the client's walking difficulty.
Exhibit 1 Nurses' Notes 1315:
Client is postoperative following an open cholecystectomy, Client's partner is at bedside. Surgical dressing intact, with small amount of serosanguineous drainage on dressings. Client reports pain as 5 on a scale of 0 to 10. Client requests a dose of their pain medication. Client expresses concern regarding the cost of prescription medications. Client reports being unable to find transportation to follow-up appointment
Plan of Care
1300:
Case management referral for discharge planning.
Client will need home health referral for dressing changes Client to follow up with the provider at the clinic in 1 week.
A nurse case manager is reviewing the electronic medical record of a postoperative client. Click to highlight the findings that require follow-up by the case manager.
- A. Client reports being unable to find transportation to follow-up appointment
- B. Client expresses concern regarding the cost of prescription medications
- C. Case management referral for discharge planning
- D. Client will need home health referral for dressing changes
Correct Answer: A
Rationale: []
Rationale:
- Correct Answer (A): The client reporting being unable to find transportation to the follow-up appointment is a critical issue that requires immediate follow-up by the case manager to ensure continuity of care and adherence to the treatment plan.
- Incorrect Answer (B): Although concerns about the cost of prescription medications are important, they do not directly relate to the immediate follow-up needed postoperatively.
- Incorrect Answer (C): Case management referral for discharge planning is essential but does not specifically address the immediate follow-up after the postoperative period.
- Incorrect Answer (D): While the client needing a home health referral for dressing changes is important, it does not pertain to the immediate follow-up that the case manager needs to address.
Nurses on an inpatient care unit are working to help reduce unit costs. Which of the following actions is appropriate to include in the cost-containment plan?
- A. Use clean gloves rather than sterile gloves for colostomy care.
- B. Store opened bottles of normal saline in a refrigerator for up to 48 hr.
- C. Return unused supplies from the bedside to the unit's supply stock.
- D. Wait to dispose of sharps containers until they are completely full.
Correct Answer: C
Rationale: The correct answer is C: Return unused supplies from the bedside to the unit's supply stock. This action helps reduce waste by ensuring that supplies are not being unnecessarily discarded. By returning unused supplies, the unit can minimize unnecessary expenditures on restocking items that could have been used if properly managed. Additionally, it promotes efficient resource utilization and cost savings by preventing duplicate purchases.
Incorrect choices:
A: Using clean gloves rather than sterile gloves for colostomy care may compromise patient safety and increase the risk of infection.
B: Storing opened bottles of normal saline in a refrigerator for up to 48 hours may lead to contamination and compromise patient safety.
D: Waiting to dispose of sharps containers until they are completely full may increase the risk of needle-stick injuries and pose safety hazards.
A charge nurse notices that two staff nurses are not taking meal breaks during their shifts. Which of the following actions should the nurse take first?
- A. Determine the reasons the nurses are not taking scheduled breaks.
- B. Provide coverage for the nurses' breaks.
- C. Review facility policies for taking scheduled breaks.
- D. Discuss time management strategies with the nurses.
Correct Answer: A
Rationale: Determining the reasons for not taking breaks identifies the root cause, enabling targeted solutions to ensure staff well-being.
A nurse in the emergency department is preparing to care for a client who arrived via ambulance. The client is disoriented and has a cardiac arrhythmia. Which of the following actions should the nurse take?
- A. Contact the client's next of kin to obtain consent for treatment.
- B. Notify risk management before initiating treatment.
- C. Have the client sign a consent for treatment.
- D. Proceed with treatment without obtaining written consent
Correct Answer: D
Rationale: The correct answer is D: Proceed with treatment without obtaining written consent. In emergency situations, the priority is providing immediate care to stabilize the client's condition. Obtaining written consent can delay treatment, which could be life-threatening for the client. Contacting next of kin (A), notifying risk management (B), and having the client sign a consent form (C) are not appropriate in this critical situation as they all involve unnecessary steps that could compromise the client's health. The nurse's primary responsibility is to ensure the client's safety and well-being by promptly addressing the cardiac arrhythmia.