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A nurse is caring for a client who is scheduled for surgery but is hesitant to sign the consent form. Which of the following actions should the nurse take first?
- A. Notify the surgeon of the client's hesitation.
- B. Document the client's refusal to sign the consent form.
- C. Ask the client about their concerns regarding the surgery.
- D. Contact the client's family to discuss the procedure.
Correct Answer: C
Rationale: Asking the client about their concerns allows the nurse to address specific fears or misunderstandings, promoting informed consent and respecting the client's autonomy.
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A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following instructions should the nurse include in the teaching?
- A. Use wool blankets on your bed.
- B. Store unused oxygen tanks horizontally.
- C. Check your oxygen equipment once each week.
- D. Do not adjust the oxygen flow rate.
Correct Answer: D
Rationale: The correct answer is D: Do not adjust the oxygen flow rate. This is crucial to prevent complications such as hypoxia or oxygen toxicity. Adjusting the flow rate without medical guidance can be dangerous. A: Using wool blankets can increase the risk of fire hazard. B: Storing unused oxygen tanks horizontally can cause leaks due to the pressure change. C: Checking equipment weekly is important, but not adjusting the flow rate is more critical for safety.
A nurse has assigned client care activities to an assistive personnel (AP). Which of the following statements by the AP Indicates a need for assistance in establishing priorities?
- A. I have my assignment and will start with room 1, then work my way to room 10.
- B. After breakfast, I will pack the belongings of clients who will be discharged this morning.
- C. I will start by providing partial baths before breakfast.
- D. I will give this client his meal tray first, as he is going early to physical therapy.
Correct Answer: A
Rationale: The correct answer is A because the AP's statement lacks prioritization based on client needs or acuity. Starting with room 1 and working way to room 10 may not address urgent needs. Choice B demonstrates an understanding of the timely task of packing for discharged clients. Choice C indicates a proactive approach to hygiene needs. Choice D highlights prioritizing based on a client's scheduled activity. Overall, choice A lacks a clear understanding of prioritization in client care, making it the correct answer.
A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?
- A. Dilated pupils
- B. Euphoria
- C. Rhinorrhea
- D. Hallucinations
Correct Answer: B
Rationale: The correct answer is B: Euphoria. Opioid medications can cause euphoria as they act on the brain's reward system, leading to feelings of pleasure and well-being. This can contribute to their potential for misuse and diversion. Dilated pupils (A) are a common side effect of opioid use, not an adverse effect. Rhinorrhea (C) refers to a runny nose and is not typically associated with opioid use. Hallucinations (D) are rare but possible with high doses or in susceptible individuals. In summary, euphoria is a known adverse effect of opioid medications, making it the correct choice.
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 nurse is assisting a newly licensed nurse with delegating tasks to an assistive personnel on the unit. Which of the following statements by the nurse explains the purpose of delegation?
- A. Delegation provides appropriate resources for the client.
- B. Delegation promotes discharge teaching activities for clients.
- C. Delegation permits a designated individual to meet a goal on your behalf.
- D. Delegation decreases health care costs.
Correct Answer: C
Rationale: Rationale: Answer C is correct because delegation allows a designated individual to accomplish a specific task or goal on behalf of the delegator. This ensures efficient and effective delivery of care while maximizing resources. Option A is incorrect as it refers to resource allocation, not delegation's purpose. Option B is incorrect as delegation is not solely for discharge teaching. Option D is incorrect as while delegation may contribute to cost-effectiveness, it is not its primary purpose.