Nokea
A nurse is discussing the norming stage of the group development process with a student nurse. Which of the following statements by the student indicates understanding of the discussion?
- A. This stage is when testing occurs to identify boundaries of interpersonal behaviors.
- B. Consensus evolves in this stage.
- C. This stage involves constructive efforts on the part of the group members.
- D. Resistance is evident as subgroups form in this stage.
Correct Answer: B
Rationale: The correct answer is B: Consensus evolves in this stage. During the norming stage of group development, members begin to resolve conflicts and establish norms and values. Consensus-building is crucial in this stage to ensure everyone is on the same page and working towards common goals. This process helps the group to develop cohesion and unity.
Choice A is incorrect because testing occurs in the forming stage, not norming. Choice C is incorrect because constructive efforts typically occur in the performing stage, not norming. Choice D is incorrect because resistance and subgroup formation usually happen in the storming stage, not norming.
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A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?
- A. Place a black tag on the client’s upper body and attempt to help the next client in need.
- B. Reposition the client’s upper airway a second time before assessing his respirations.
- C. Start CPR.
- D. Place a red tag on the client’s upper body and obtain immediate help from other personnel.
Correct Answer: A
Rationale: The correct answer is A: Place a black tag on the client’s upper body and attempt to help the next client in need. In this scenario, the client is apneic despite repositioning the airway and has a weak pulse. The client's condition falls under "expectant" during triage, indicated by a black tag. The nurse should prioritize helping those who have a higher chance of survival first. Placing a black tag and moving on to assist others is essential to maximize the number of lives saved in a mass casualty event. Starting CPR (choice C) may be futile if the client is trapped under a car with severe injuries. Choice B, repositioning the airway again, is unlikely to change the client's apneic status. Choice D, placing a red tag, is incorrect as this tag is typically used for immediate care cases.
A nurse is caring for a client who is participating in a research study for an experimental chemotherapy medication. After three treatments, the experimental medication is discontinued due to evidence of rapidly advancing kidney failure. The nurse should understand discontinuing this medication demonstrates which of the following ethical principles?
- A. Veracity
- B. Fidelity
- C. Nonmaleficence
- D. Autonomy
Correct Answer: C
Rationale: The correct answer is C: Nonmaleficence. This principle of ethics requires healthcare providers to do no harm to their patients. In this scenario, discontinuing the experimental chemotherapy medication after evidence of rapidly advancing kidney failure demonstrates the nurse's commitment to preventing further harm to the client. By stopping the medication that is causing harm, the nurse is upholding the principle of nonmaleficence.
Other choices are incorrect:
A: Veracity - Veracity pertains to truthfulness and honesty in communication with patients. Discontinuing the medication is not related to truthfulness.
B: Fidelity - Fidelity refers to the obligation to fulfill commitments and promises made to patients. Discontinuing the medication is not about fulfilling commitments.
D: Autonomy - Autonomy is the right of patients to make their own decisions about their healthcare. Discontinuing the medication is not about respecting the patient's autonomy in this context.
A nurse is caring for a client following the surgical placement of a colostomy. Which of the following statements indicates the client understands the dietary teaching?
- A. Your largest meal of the day should be in the evening.
- B. Eating yogurt can help decrease the amount of gas that I have.
- C. Carbonated beverages can help control odor.
- D. I should eliminate pasta from my diet so that I don’t have many loose stools.
Correct Answer: B
Rationale: The correct answer is B because eating yogurt can help decrease gas due to its probiotic properties which aid in digestion. This statement shows the client understands dietary adjustments post-colostomy surgery. Choice A is incorrect as meal distribution does not affect colostomy care. Choice C is incorrect as carbonated beverages can worsen odor. Choice D is incorrect as pasta is not necessarily a problematic food post-colostomy.
A nurse is preparing to administer amitriptyline 150 mg PO at bedtime. The amount available is amitriptyline 75 mg tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: The nurse should administer 2 tablets of amitriptyline 75 mg each to achieve a total dose of 150 mg. Since each tablet is 75 mg, 2 tablets would equal 150 mg. This ensures the patient receives the prescribed dose accurately. Other choices are incorrect because administering 1 tablet would result in only 75 mg, insufficient for the prescribed dose. Administering 3 tablets would exceed the prescribed dose, leading to potential overdose. Choices above 3 tablets are also incorrect as they would significantly exceed the prescribed 150 mg dose, risking adverse effects.
A nurse is planning care for a client who is 2 hours postoperative following a transurethral resection of the prostate. The client is receiving continuous bladder irrigation. Which of the following interventions should the nurse include?
- A. Restrict the client’s oral fluid intake.
- B. Remind the client he might feel a constant urge to void.
- C. Weigh the client every evening.
- D. Monitor the client’s urine output every 6 hours.
Correct Answer: B
Rationale: The correct answer is B: Remind the client he might feel a constant urge to void. After a transurethral resection of the prostate, continuous bladder irrigation is often used to prevent blood clots and ensure urine output. This procedure can cause the client to feel a constant urge to void due to the bladder being continuously filled and emptied. Therefore, reminding the client about this sensation can help alleviate anxiety and discomfort.
Choice A: Restricting the client's oral fluid intake is incorrect because maintaining hydration is essential postoperatively to prevent complications such as dehydration and urinary retention.
Choice C: Weighing the client every evening is unnecessary and not directly related to the care of a client post transurethral resection of the prostate.
Choice D: Monitoring the client's urine output every 6 hours is important, but reminding the client about the sensation of constant urge to void takes priority in this scenario.