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A nurse is caring for a client who wanders through the halls yelling obscenities at staff, other clients, and visitors. Which of the following actions should the nurse take?
- A. Keep the client in their room with the door closed
- B. Contact a family member to come and sit with the client
- C. Place the client in a wheelchair with a lap tray
- D. Administer a sedative to the client
Correct Answer: B
Rationale: When dealing with a client exhibiting disruptive behavior like yelling obscenities, involving a family member can provide emotional support and help in de-escalating the situation. Keeping the client isolated in their room (Choice A) may lead to further agitation. Placing the client in a wheelchair (Choice C) or administering a sedative (Choice D) should not be the first interventions for managing behavioral issues.
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A nurse is orienting a newly licensed nurse about client confidentiality. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. I can use another nurse's password as long as I log off after using the computer
- B. I should encrypt personal health information when sending emails
- C. I can post the client's vital signs in the client's room
- D. I should discard personal health information documents in the trash before leaving the unit
Correct Answer: B
Rationale: The correct answer is B because encrypting personal health information when sending emails is a crucial aspect of maintaining client confidentiality. This process ensures that sensitive information is protected during electronic communication. Choice A is incorrect as sharing passwords violates client confidentiality. Choice C is incorrect as posting client's vital signs breaches confidentiality. Choice D is incorrect as discarding personal health information in the trash can lead to unauthorized access.
Round off these numbers to the nearest tenth:
- A. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
- B. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
- C. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
- D. 5.5778 = 5.6, 1.027 = 1.0, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7
Correct Answer: B
Rationale: The correct answer is B. When rounding off to the nearest tenth, 1.027 becomes 1.0 because the digit in the hundredth's place is less than 5. For the other numbers, they are rounded correctly to the nearest tenth: 5.5778 = 5.6, 62.999 = 63, 55.123 = 55.1, 96.676 = 96.7. Therefore, option B is the most accurate in rounding off these numbers to the nearest tenth. Choices A, C, and D are incorrect as they do not round 1.027 to 1.0 as required when rounding to the nearest tenth.
A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?
- A. Measuring oxygen saturation for a client who has dyspnea
- B. Inserting a rectal suppository for a client who is vomiting
- C. Performing nasal hygiene for a client who has an NG tube
- D. Pouching a client's ostomy bag for a new colostomy
Correct Answer: D
Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.
What is the purpose of a healthcare audit?
- A. To increase paperwork
- B. To assess and improve quality of care
- C. To reduce patient satisfaction
- D. To limit healthcare services
Correct Answer: B
Rationale: The correct answer is B: 'To assess and improve quality of care.' Healthcare audits are conducted to evaluate the quality and efficiency of healthcare services provided. Choice A, 'To increase paperwork,' is incorrect as audits aim to streamline processes and reduce unnecessary paperwork. Choice C, 'To reduce patient satisfaction,' is incorrect as audits are meant to identify areas for improvement to enhance patient satisfaction. Choice D, 'To limit healthcare services,' is also incorrect as audits help in optimizing healthcare services rather than limiting them.
A client with DM states, 'I cannot eat big meals; I prefer to snack throughout the day.' The nurse should carefully explain that the:
- A. Regulated food intake is crucial for control
- B. Restricting salt and sugar is the main concern
- C. Opting for small, frequent meals aids digestion
- D. Consuming large meals can contribute to weight issues
Correct Answer: A
Rationale: In clients with diabetes, regulated food intake is crucial for controlling blood glucose levels. Choice A is the correct answer because maintaining consistent meal sizes and timings helps in managing blood sugar levels effectively. Choice B is incorrect because while monitoring salt and sugar intake is important, it is not the primary consideration in this scenario. Choice C is incorrect as the focus is on regulating food intake rather than aiding digestion. Choice D is also incorrect because consuming large meals can indeed lead to fluctuations in blood glucose levels, but the primary concern in this case is the regulation of food intake for better control of diabetes.