Nokea
Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP)
indicates the most urgent need for the nurse’s assessment of the patient?
- A. Bedtime glucose of 140 mg/dL
- B. Noon blood glucose of 52 mg/dL
- C. Fasting blood glucose of 130 mg/dL
- D. 2-hr postprandial glucose of 220 mg/dL
Correct Answer: B
Rationale: The correct answer is B: Noon blood glucose of 52 mg/dL. This value indicates hypoglycemia, which can lead to serious complications like confusion, seizures, or coma. Immediate assessment and intervention are crucial.
A: Bedtime glucose of 140 mg/dL is within the normal range.
C: Fasting blood glucose of 130 mg/dL is slightly elevated but doesn't require urgent assessment.
D: 2-hr postprandial glucose of 220 mg/dL is elevated but not as critical as hypoglycemia.
You may also like to solve these questions
A resident on night call refuses to answer pages from the staff nurse on the night shift and complains that she calls too often with minor problems. The nurse feels offended and reacts with frequent, middle-of-the-night phone calls to 'get back' at him. The behavior displayed by the resident and the nurse is an example of what kind of conflict?
- A. Perceived conflict
- B. Disruptive conflict
- C. Competitive conflict
- D. Felt conflict
Correct Answer: B
Rationale: The correct answer is B: Disruptive conflict. This type of conflict occurs when individuals are unwilling to cooperate or communicate effectively, leading to negative consequences. In this scenario, the resident and nurse are engaging in disruptive conflict by refusing to answer calls and retaliating with more calls. This behavior disrupts the communication and collaboration necessary for effective patient care.
A: Perceived conflict is when individuals believe there is a conflict, even if it may not exist. In this case, the conflict is real and not just perceived.
C: Competitive conflict involves individuals trying to outdo each other or win at the expense of the other party. This is not evident in the scenario provided.
D: Felt conflict refers to the emotional response to a conflict situation. While there are emotions involved in the scenario, the main issue is the disruption in communication rather than just feelings.
When trying to facilitate change in the staff, it is necessary to build trust and recognize the need for change. This type of action is known as which of the following, according to Lewin's Force-Field Model?
- A. Moving the system to a new level
- B. Unfreezing the system
- C. Refreezing the system
- D. Institutionalization
Correct Answer: B
Rationale: The correct answer is B: Unfreezing the system. In Lewin's Force-Field Model, unfreezing refers to the process of preparing individuals and systems for change by breaking down existing mindsets and behaviors. Building trust and recognizing the need for change are essential steps in unfreezing. Moving the system to a new level (A) is not specific to the initial stage of change. Refreezing the system (C) occurs after change has been implemented, not before. Institutionalization (D) involves integrating the change into the organization's culture, which is a later stage in the change process.
An RN is writing reminders for good documentation for the nurses on her staff. The purpose is to ensure nursing documentation is legally credible. Which of the following is a recommendation she should include in the reminders?
- A. Use shortcuts in documentation.
- B. Only use approved abbreviations.
- C. Documentation should be subjective.
- D. Document after care is provided.
Correct Answer: B
Rationale: The correct answer is B: Only use approved abbreviations. Using approved abbreviations in nursing documentation helps ensure clarity, accuracy, and consistency, which are crucial for legal credibility. Abbreviations can lead to misunderstandings or errors if not standardized.
Explanation for other choices:
A: Using shortcuts in documentation can compromise accuracy and lead to incomplete or unclear information, which could result in legal issues.
C: Documentation should be objective, not subjective, to provide an accurate portrayal of the patient's condition and care. Subjective documentation can be challenged legally.
D: Documenting after care is provided is important, but documenting in a timely manner is crucial for legal credibility. Delayed documentation can raise questions about the accuracy and reliability of the information.
An RN knows that sometimes, when working through an ethical dilemma, the decision makers are unable to arrive at a mutually agreed upon decision. Which of the following is a reason why an agreement cannot be reached?
- A. One or more of the parties may be able to reconcile their values.
- B. The patient’s point of view is recognized as valuable.
- C. The dilemma involves two or more equally unpleasant choices.
- D. The institution is unable to honor the patient’s request.
Correct Answer: C
Rationale: The correct answer is C because when an ethical dilemma involves two or more equally unpleasant choices, it can be challenging for decision-makers to come to a consensus. This is known as a moral dilemma, where there is no clear right or wrong option, making it difficult to reach an agreement. In such cases, individuals may have strong convictions about different courses of action, leading to a deadlock in decision-making.
Incorrect choices:
A: One or more of the parties may be able to reconcile their values - This choice suggests that parties can find common ground by adjusting their values, which is not always possible in complex ethical dilemmas.
B: The patient’s point of view is recognized as valuable - While recognizing the patient's perspective is important, it may not directly address the core reason why an agreement cannot be reached.
D: The institution is unable to honor the patient’s request - This choice focuses on institutional constraints rather than the fundamental nature of ethical dilemmas and decision-making processes.
A client is refusing a blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should be taken?
- A. Ask the client to consider a direct donation
- B. Withhold the blood transfusion
- C. Ask the client to consider a direct donation
- D. Request a consultation with the ethics committee
Correct Answer: A
Rationale: The correct answer is A. Asking the client to consider a direct donation respects their religious beliefs while also addressing the partner's concerns. This option promotes patient autonomy and involves the client in decision-making.
B: Withholding the blood transfusion disregards the client's autonomy and may lead to ethical issues.
C: This is a repeated option and does not provide a different course of action.
D: Requesting a consultation with the ethics committee may delay necessary treatment and should be considered only when there is a significant ethical dilemma beyond this situation.