Nokea
A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report?
- A. The client's input & output for the shift
- B. The client's BP from the previous day
- C. A bone scan that is scheduled for today
- D. The med routine from the med administration record
Correct Answer: C
Rationale: The correct answer is C: A bone scan that is scheduled for today. Including this information in the report is crucial as it alerts the oncoming nurse about the upcoming procedure, allowing them to plan and prepare accordingly. This is important for ensuring the client receives timely and appropriate care. The other choices are incorrect because: A (input & output) is important but may not be the priority for a change-of-shift report; B (BP from the previous day) is outdated information and may not be relevant for the current shift; D (med routine) should be documented in the client's chart and can be accessed by the oncoming nurse as needed.
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A client who had abdominal surgery 24 hr ago reports a pulling sensation & pain in his surgical incision. The nurse checks the client's surgical wound and finds the wound separated with viscera protruding. Which of the following interventions is appropriate? Select all.
- A. Cover the area with saline-soaked sterile dressings
- B. Apply an abdominal binder snugly around the abdomen
- C. Use sterile gloves to apply gentle pressure to the exposed tissues
- D. Position the client supine with hips & knees bent
- E. Offer the client a warm beverage, such as herbal tea
Correct Answer: A, D
Rationale: Correct Answer: A, D
Rationale:
1. Covering the area with saline-soaked sterile dressings (Choice A) helps to protect the exposed tissues, prevent infection, and maintain a moist environment for healing.
2. Positioning the client supine with hips and knees bent (Choice D) can help reduce tension on the wound, alleviate pain, and minimize the risk of further tissue damage.
Summary:
- Applying an abdominal binder (Choice B) may increase pressure on the wound, exacerbating the situation.
- Using sterile gloves to apply pressure to exposed tissues (Choice C) can introduce contamination and should be avoided.
- Offering a warm beverage (Choice E) is irrelevant and does not address the urgent need to manage the wound.
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy & unable to focus on the issue at hand. Today, she found the nurse asleep in a chair in the break room when she was not on break. Which of the following actions should the nurse take?
- A. Remind the nurse that safe client care is a priority on the unit
- B. Ask others on the team whether they have observed the same behavior
- C. Report observations to the nurse manager on the unit
- D. Conclude that her coworker's fatigue is not her problem to solve
Correct Answer: C
Rationale: The correct action is to choose option C: Report observations to the nurse manager on the unit. This is the most appropriate course of action because it addresses the potential safety risk to patients due to the drowsy nurse's behavior. Reporting to the nurse manager ensures that the issue is escalated to someone in authority who can address it effectively, such as through a conversation with the drowsy nurse, adjusting their work schedule, or providing support if there are underlying issues causing the fatigue. Options A, B, and D are not as effective because reminding the nurse or asking others on the team may not lead to a resolution, and assuming the fatigue is not the nurse's problem to solve ignores the potential impact on patient safety.
A nurse is preparing to administer lactated Ringer's (LR) IV 100 mL over 15 minutes. The nurse should set the infusion pump to deliver how many mL/hr?
Correct Answer: 400
Rationale: The correct answer is 400 mL/hr. To calculate the mL/hr rate, we first convert the 15 minutes to hours (15 minutes ÷ 60 minutes = 0.25 hours). Then, we divide the total volume (100 mL) by the time in hours (100 mL ÷ 0.25 hours = 400 mL/hr). This rate ensures the safe and accurate administration of 100 mL of LR over a 15-minute period. Other choices are incorrect because they do not accurately calculate the mL/hr rate based on the given parameters.
A nurse is preparing an in-service program about delegation. Which of the following elements should she identify when presenting the 5 rights of delegation?
- A. "Right client"
- B. Right supervision/evaluation
- C. Right direction/communication
- D. Right time
- E. Right circumstances
Correct Answer: B, C, E
Rationale: The correct answer is B, C, and E. The 5 rights of delegation are essential for safe and effective delegation. Right supervision/evaluation ensures appropriate oversight, feedback, and accountability. Right direction/communication emphasizes clear instructions and open communication. Right circumstances consider factors like workload and resources. Right client (choice A) and right time (choice D) are not part of the 5 rights of delegation. In summary, choices A and D are incorrect because they do not align with the established principles of delegation, while choices B, C, and E are crucial components for successful delegation.
A nurse is caring for an older adult client who lives alone & is to be discharged in 3 days. He states that it is difficult to prepare adequate nutritious meals at home for just 1 person. To which of the following members of the health care team should the nurse refer him?
- A. Registered dietitian
- B. Occupational therapist
- C. Physical therapist
- D. Social worker
Correct Answer: D
Rationale: The correct answer is D: Social worker. The social worker can help the older adult client access community resources such as meal delivery services, food assistance programs, or senior centers that provide nutritious meals. The social worker can also assess the client's social support system and address any other psychosocial needs that may impact his ability to prepare meals. Referring to a registered dietitian (choice A) may address the nutritional aspect but not the underlying social issues. Occupational therapists (choice B) focus on improving activities of daily living, physical therapists (choice C) focus on physical rehabilitation, which are not directly related to meal preparation difficulties.