Nokea
A nurse is preparing a change-of-shift report. Which of the following tools or documents should the nurse use to communicate continuity of care?
- A. Critical pathway
- B. Situation background assessment and recommendation (SBAR)
- C. Transfer report
- D. Medication administration record (MAR)
Correct Answer: B
Rationale: The correct answer is B: Situation background assessment and recommendation (SBAR). SBAR is a structured communication tool used in healthcare to provide a concise and focused way of relaying important information between healthcare team members. It helps ensure continuity of care by including essential details such as the patient's situation, background information, assessment findings, and recommendations for further care. SBAR improves communication efficiency, reduces errors, and enhances patient safety.
Choices A, C, and D are incorrect because:
A: Critical pathway is a care plan outlining evidence-based guidelines for patient care but does not provide the detailed communication needed for continuity of care.
C: Transfer report is focused on the transfer of a patient between units or facilities and may not include all the necessary information for continuity of care during a shift change.
D: Medication administration record (MAR) is a document used to record medication administration and does not encompass the comprehensive patient information needed for effective shift handoff.
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A nurse is preparing to administer an injection of an opioid medication to a client. The nurse draws out 1 mL of the medication from a 2 mL vial. Which of the following actions should the nurse take?
- A. Ask another nurse to observe the medication wastage.
- B. Notify the pharmacy when wasting the medication.
- C. Lock the remaining medication in the controlled substances cabinet.
- D. Dispose of the vial with the remaining medication in a sharps container.
Correct Answer: C
Rationale: The correct answer is C: Lock the remaining medication in the controlled substances cabinet. This is the correct action because opioids are controlled substances that require strict security measures to prevent diversion or misuse. By locking the remaining medication in the controlled substances cabinet, the nurse ensures that it is securely stored and accounted for.
Choice A: Asking another nurse to observe the medication wastage is unnecessary in this situation as the remaining medication should be properly secured rather than observed.
Choice B: Notifying the pharmacy when wasting the medication may be required for documentation purposes, but it does not address the immediate need to secure the remaining medication.
Choice D: Disposing of the vial with the remaining medication in a sharps container is incorrect as it does not follow proper protocol for handling controlled substances.
In summary, choice C is the correct action as it aligns with the necessary security measures for handling opioids, while the other choices do not address the specific requirements for controlled substances.
A nurse is performing a home safety assessment for a client who is receiving supplemental oxygen. Which of the following observations should the nurse identify as proper safety protocol?
- A. The client uses a wool blanket on their bed.
- B. The client identifies the location of the fire extinguisher.
- C. The client stores an oxygen tank in a secure outdoor shed.
- D. The client has a weekly inspection checklist for oxygen equipment.
Correct Answer: D
Rationale: The correct answer is D because a weekly inspection checklist for oxygen equipment ensures that the equipment is functioning properly and reduces the risk of potential hazards. Option A is incorrect because wool blankets can create static electricity, which is a fire hazard. Option B is not directly related to oxygen safety. Option C is incorrect as storing an oxygen tank in an outdoor shed may expose it to extreme temperatures or moisture.
Vital signs:Temperature 36.2° C (97.2° F) Pulse rate 116/min Respiratory rate 24/min BP 102/68 mm Hg Oxygen saturation 95% Weight 52.2 kg (115 Ib
A nurse in a provider's clinic is caring for a client who has diarrhea. The nurse is providing teaching for the client. Select the 4 instructions the nurse should include in the teaching.
- A. Increase intake of high-calcium foods.
- B. Eat probiotic foods, such as yogurt.
- C. Avoid alcohol while experiencing diarrhea.
- D. Eat raw vegetables.
- E. Eat three large meals a day.
- F. Avoid caffeine while experiencing diarrhea.
- G. Drink lots of fluids several times a day.
Correct Answer: B, C, F, G
Rationale: The correct instructions for the nurse to include are B, C, F, and G.
B: Probiotic foods like yogurt can help restore gut health.
C: Alcohol can worsen diarrhea, so it's important to avoid it.
F: Caffeine can be irritating to the digestive system, so avoiding it is beneficial.
G: Drinking lots of fluids helps prevent dehydration from diarrhea.
These instructions are essential for managing diarrhea effectively.
Incorrect options:
A: High-calcium foods may not be well-tolerated during diarrhea.
D: Raw vegetables can be difficult to digest during diarrhea.
E: Eating three large meals can be too much for a digestive system experiencing diarrhea.
A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of a skin malignancy?
- A. A lesion with uniform pigmentation
- B. New appearance of petechiae
- C. A mole with an asymmetrical appearance
- D. The presence of a papule
Correct Answer: C
Rationale: The correct answer is C: A mole with an asymmetrical appearance. This is indicative of a potential skin malignancy such as melanoma. The asymmetry suggests irregular growth patterns, which can be a sign of cancerous cells. Other choices, such as A (lesion with uniform pigmentation), B (petechiae), and D (presence of a papule) are not specific indicators of skin malignancy. Lesions with uniform pigmentation are more likely to be benign. Petechiae are tiny red spots due to bleeding under the skin and are not typically associated with skin cancer. Papules are small raised bumps that can have various causes, not necessarily cancerous. Therefore, choice C is the most concerning finding for skin cancer based on asymmetry, prompting further evaluation and possible biopsy.
Nurses’ Notes
First Clinic Vist:
Cliet arrives to dinc with report of increasing shortness of breath, fatigue. and weakness. States they gt short of breath with minimal activiy.
Cllent s alert and oriented to person, pace, and time. Maoves allextremities well, follows simple commands. Sinus tachycardia, Pulses to lowr extremitis wesk with +2 dependent edema present,
Slightlylabored respirations at rst. Chest with wheezes and crackles n the basas. Reports productive cough, especially during the overnight hours.
Bowel sounds al presen. Abdomen distended. Reports bowel movement this am.
States voiding without dfficulty, lear yellow urine
Teaching provided on nuition therapy and adhering to & ow-sodium diet, monitoring fud intake, and Ifestyle changes for heart fallure. Provided medication teaching following provider's increase in furosemide dosage
A nurse is assessing a client with heart failure. The client reports increasing shortness of breath, fatigue, and weakness. Which of the following findings in the assessment should the nurse identify as most concerning?
- A. Weak pulses with +2 dependent edema in lower extremities.
- B. Slightly labored respirations at rest.
- C. Wheezes and crackles in the chest.
- D. Reports productive cough during the overnight hours.
Correct Answer: C
Rationale: The correct answer is C: Wheezes and crackles in the chest. This finding is most concerning in a client with heart failure as it indicates potential fluid overload in the lungs, leading to impaired gas exchange and worsening respiratory status. Wheezes suggest bronchoconstriction, while crackles indicate fluid accumulation in the alveoli, both of which can exacerbate shortness of breath. Weak pulses with dependent edema (choice A) are expected in heart failure but do not directly point to acute decompensation. Slightly labored respirations at rest (choice B) may be common in heart failure but do not indicate immediate deterioration. Reports of a productive cough (choice D) can be a sign of fluid retention but are less urgent compared to wheezes and crackles.