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A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hr. Which of the following actions should the nurse take next?
- A. Document the provider's statement in the medical record.
- B. Consult the facility's risk manager.
- C. Complete an incident report.
- D. Notify the nursing manager.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse should document the provider's statement in the medical record. This is important for legal and communication purposes. By documenting the surgeon's instructions, the nurse ensures that the care provided is well-documented and can be tracked for continuity of care. It also serves as evidence that the nurse followed the provider's orders appropriately.
Summary:
B: Consulting the facility's risk manager is not necessary at this point as the situation does not involve a risk management issue.
C: Completing an incident report is not warranted as there is no indication of an incident or error that has occurred.
D: Notifying the nursing manager is not the immediate action required in this situation. The nurse should prioritize following the provider's instructions and documenting the communication.
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A nurse in a provider's office is assessing the deep tendon reflexes of a client. Which of the following images should the nurse identify as indicating the correct technique for eliciting the client's patellar reflex?
- A. Image A: Client sitting with legs dangling over the edge of the table and the examiner tapping below the patella with a reflex hammer.
- B. Image B: Client lying down with legs extended and the examiner tapping above the patella with a reflex hammer.
- C. Image C: Client sitting with legs crossed while the examiner taps the patella with a reflex hammer.
- D. Image D: Client standing with knees slightly bent while the examiner taps the patella with a reflex hammer.
Correct Answer: A
Rationale: The correct answer is A because the image depicts the correct technique for eliciting the patellar reflex. When assessing the patellar reflex, the client should be sitting with their legs dangling over the edge of the table, and the examiner should tap below the patella with a reflex hammer. This position allows for optimal relaxation of the quadriceps muscle and easy access to the patellar tendon, resulting in a more accurate reflex response.
Choice B is incorrect because tapping above the patella can lead to an inaccurate response as it does not target the patellar tendon directly. Choices C and D are incorrect as they involve incorrect client positions that do not facilitate the proper assessment of the patellar reflex.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: C
Rationale: The correct answer is C: Provide the client with written information about the phases of loss and grief. This is the most appropriate action as the client is expressing anger, which is a normal part of the grieving process. By providing information about the phases of loss and grief, the nurse can help the client understand his emotions and cope with them effectively.
A: Discussing risk factors for colon cancer is not the immediate priority when the client is expressing anger.
B: Focusing on future management may be overwhelming for the client at this stage when he is dealing with emotional distress.
D: Reassuring the client that his response is expected is helpful, but providing information on coping mechanisms is more beneficial in this situation.
The nurse is placing the client on isolation precautions. Which of the following interventions should the nurse include? Select all that apply.
- A. Wear an N95 mask when caring for the client.
- B. Place a container for soiled linens inside the client's room.
- C. Place the client in a negative airflow room.
- D. Remove mask after exiting the client's room.
- E. Wear a sterile water-resistant gown if within 3 feet of the client.
Correct Answer: A, B, C, E
Rationale: The correct interventions for placing a client on isolation precautions include A, B, C, and E. A) Wearing an N95 mask is crucial for airborne precautions. B) Placing a container for soiled linens inside the room prevents contamination. C) A negative airflow room helps contain airborne pathogens. E) Wearing a sterile water-resistant gown within close proximity to the client prevents transmission. D is incorrect as the mask should be removed inside the client's room. Choices F and G are likely blank options or not relevant to isolation precautions.
A nurse is caring for 3 clients who have COPD. Select the 3 findings that require follow-up. Nurses' Notes: Temperature 100°F, oxygen saturation 88%, blood pressure 130/80 mmHg. Client admitted with a productive cough with thick yellow sputum. Breath sounds with crackles heard in the left upper lobe and decreased breath sounds at bases bilaterally. Heart rate 98 beats/min.
- A. Temperature 100°F
- B. Oxygen saturation 88%
- C. Blood pressure 130/80 mmHg
- D. Heart rate 98 beats/min
Correct Answer: A, B, D
Rationale: The correct answers are A, B, and D. A temperature of 100°F indicates possible infection or inflammation, warranting follow-up. An oxygen saturation of 88% is below the normal range, indicating hypoxemia. A heart rate of 98 beats/min is elevated, suggesting increased work of breathing or stress on the cardiovascular system. Choice C, blood pressure of 130/80 mmHg, falls within the normal range and does not require immediate follow-up. Choices E, F, and G are not relevant findings in this scenario.
A nurse manager is preparing to review medication documentation with a group of newly licensed nurses. Which of the following statements should the nurse manager plan to include in the teaching?
- A. Use the complete name of the medication magnesium sulfate.
- B. Distinguish the space between the numerical dose and the unit of measure.
- C. Write the letter U when noting the dosage of insulin.
- D. Use the abbreviation SC when indicating an injection.
Correct Answer: A
Rationale: The correct answer is A: Use the complete name of the medication magnesium sulfate. This is important because using the complete name of the medication helps prevent medication errors and ensures clarity in communication. It also follows best practices for medication safety.
Choice B is incorrect because while distinguishing the space between the numerical dose and the unit of measure is important for clarity, it is not as critical as using the complete name of the medication.
Choice C is incorrect because when noting the dosage of insulin, it is important to use the unit "units" rather than the letter "U" for accuracy and clarity.
Choice D is incorrect because the correct abbreviation for indicating a subcutaneous injection is "SQ" or "subQ," not "SC."
Overall, using the complete name of the medication is the most crucial aspect in medication documentation to ensure patient safety and prevent errors.