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A nurse is gathering evidence-based practice on catheter-associated urinary tract infections (CAUTI). Which of the following roles is the nurse performing?
- A. Researcher
- B. Nurse manager
- C. Case manager
- D. Educator
Correct Answer: A
Rationale: The correct answer is A: Researcher. The nurse is gathering evidence-based practice on CAUTI, which involves conducting research to gather relevant information, analyze data, and draw conclusions based on evidence. This role aligns with the responsibilities of a researcher who systematically investigates a topic to contribute to the body of knowledge. The other choices are incorrect because: B: Nurse managers oversee nursing staff and operations, C: Case managers coordinate patient care, and D: Educators focus on teaching and disseminating knowledge. In this scenario, the nurse's primary role is to gather evidence through research, making option A the most appropriate choice.
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A nurse is delegating care for a group of four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach the use of an incentive spirometer to a postoperative client
- B. Irrigate and perform a dressing change for a client who has a pressure injury wound
- C. Administer oral PRN pain medication to a client who has arthritis
- D. Obtain a daily weight on a client who has heart failure
Correct Answer: D
Rationale: The correct answer is D: Obtain a daily weight on a client who has heart failure. The rationale is as follows: Delegating the task of obtaining a daily weight to an assistive personnel (AP) is appropriate because it is a routine, non-invasive task that does not require specialized knowledge or skills. Daily weight monitoring is crucial for clients with heart failure to assess for fluid retention or loss, which is essential for managing the condition effectively. APs are trained to perform basic tasks like measuring weight and can report any significant changes to the nurse for further evaluation.
Summary of why the other choices are incorrect:
A: Teaching the use of an incentive spirometer requires specialized knowledge and skill that only a nurse should perform.
B: Irrigating and performing a dressing change for a pressure injury wound requires sterile technique and assessment skills that are beyond the scope of an AP.
C: Administering PRN pain medication involves assessing the client's condition, pain level, and potential side effects,
A nurse is caring for a client who has a terminal diagnosis and states, 'I am ready to update my will.' The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?
- A. Denial
- B. Acceptance
- C. Anger
- D. Bargaining
Correct Answer: B
Rationale: The correct answer is B: Acceptance. The client expressing readiness to update their will indicates acceptance, one of the stages of grief according to Kubler-Ross. This stage involves coming to terms with the reality of the situation and making necessary preparations. Denial (choice A) involves refusing to accept the diagnosis, anger (choice C) involves feelings of frustration and unfairness, and bargaining (choice D) involves seeking ways to avoid the inevitable. In this scenario, the client's statement aligns with the acceptance stage, as they are taking practical steps to prepare for the future.
A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)?
- A. Heart failure
- B. Brainstem injury
- C. Recent weight loss
- D. Enlarged tonsils
Correct Answer: D
Rationale: The correct answer is D: Enlarged tonsils. Enlarged tonsils can physically obstruct the airway during sleep, leading to obstructive sleep apnea (OSA). This obstruction causes pauses in breathing during sleep, resulting in disrupted sleep patterns and decreased oxygen levels in the blood. Heart failure (A) is incorrect because it is not a direct cause of OSA. Brainstem injury (B) may disrupt the sleep-wake cycle but is not a common cause of OSA. Recent weight loss (C) can actually improve OSA symptoms by reducing the amount of tissue in the airway. Therefore, the most likely condition to cause OSA among the choices given is enlarged tonsils.
A nurse is caring for a client who has a Penrose drain. Which of the following actions should the nurse take?
- A. Clean the skin near the drain in a circular motion from the outside to the inside
- B. Empty the drainage device when it is half full
- C. Place a perforated gauze pad around the drain to absorb drainage
- D. Connect the drain to continuous low-pressure suction
Correct Answer: C
Rationale: Rationale: Choice C is correct because placing a perforated gauze pad around the drain helps absorb drainage and prevents skin irritation. This promotes wound healing and prevents infection. Choice A is incorrect as it can introduce bacteria into the wound. Choice B is incorrect because drainage should be emptied when it reaches a certain level, not necessarily when it is half full. Choice D is incorrect as Penrose drains do not require suction.
A nurse is teaching a newly licensed nurse about preventing puncture injuries. Which of the following instructions should the nurse include?
- A. Break needles on syringes before disposal
- B. Use two hands to recap a needle after administering a medication
- C. Dispose of used razors in wastebaskets
- D. Replace sharps containers when they are 3/4 full
Correct Answer: D
Rationale: The correct answer is D: Replace sharps containers when they are 3/4 full. This instruction is crucial in preventing puncture injuries as overfilling sharps containers can increase the risk of accidental needle sticks. By replacing the containers when they are 3/4 full, it ensures that there is enough space to safely dispose of needles and other sharp objects without risking spills or injuries.
Explanation of other choices:
A: Breaking needles on syringes before disposal is unsafe as it can increase the risk of needle stick injuries.
B: Using two hands to recap a needle is dangerous and not recommended as it can lead to accidental needle sticks.
C: Disposing of used razors in wastebaskets is improper as they should be disposed of in puncture-proof containers.
Summary: Option D is the correct choice as it emphasizes safe disposal practices to prevent puncture injuries, while the other options promote unsafe practices that can increase the risk of needle stick injuries.