Nokea
A nurse is preparing to discharge a client who requires home oxygen. The equipment company has not yet delivered the oxygen tank. Which of the following actions should the nurse take?
- A. Send an oxygen tank from the facility home with the client
- B. Instruct the client's family to contact the insurance provider about the oxygen equipment
- C. Contact social services about the delivery of the oxygen equipment
- D. Notify the provider about the delayed oxygen tank delivery
Correct Answer: C
Rationale: The correct action for the nurse to take is to contact social services about the delivery of the oxygen equipment. This ensures that the necessary equipment is delivered to the client's home promptly. Choice A is incorrect because sending an oxygen tank from the facility is not a sustainable solution and may lead to legal and safety issues. Choice B is incorrect as contacting the insurance provider is not the appropriate course of action to address the delayed delivery. Choice D is also incorrect because notifying the provider about the delay may not directly lead to the timely delivery of the oxygen equipment.
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A nurse at a long-term care facility is planning a fall prevention program for the residents. Which of the following interventions should the nurse include?
- A. Apply vest restraints to residents who are confused
- B. Keep all four side rails up on beds at night
- C. Accompany residents over 85 years of age during ambulation
- D. Implement rounds every 2 hours during the day to offer toileting
Correct Answer: D
Rationale: The correct answer is to implement rounds every 2 hours during the day to offer toileting. This intervention helps prevent falls by addressing the common cause of unassisted mobility, which is the need to use the bathroom. Choice A is incorrect as restraints should not be the first choice for fall prevention due to the risk of injury and loss of independence. Choice B is incorrect because all side rails up can lead to entrapment and should only be used based on individualized assessments. Choice C may not be feasible for all residents over 85 years old and does not directly address the risk of falls.
When reinforcing teaching and instructing the patient, which basic principle of teaching should you follow?
- A. Sequence the instruction from the least complex to the most complex.
- B. Assume that the patient knows little or nothing about the topic.
- C. Tell the patient to call their significant other so you can instruct them.
- D. Use medically oriented terms so the patient will be able to speak with the doctor.
Correct Answer: A
Rationale: The correct principle of teaching to follow when reinforcing teaching and instructing the patient is to sequence the instruction from the least complex to the most complex. This approach facilitates learning by building upon simpler concepts before moving to more advanced ones. Choice B is incorrect because assuming the patient knows little or nothing about the topic may not always be accurate and can be patronizing. Choice C is incorrect as it does not focus on the direct teaching approach to the patient. Choice D is incorrect as using medically oriented terms may confuse the patient rather than facilitate understanding.
Which of the following assessment tools is used to determine the patient's level of consciousness?
- A. The Snellen Scale
- B. The Norton Scale
- C. The Morse Scale
- D. The Glasgow Scale
Correct Answer: D
Rationale: The correct answer is D, The Glasgow Scale. The Glasgow Coma Scale is specifically designed to assess a patient's level of consciousness by evaluating eye opening, verbal response, and motor response. Choices A, B, and C are incorrect because the Snellen Scale is used for vision testing, the Norton Scale is used for assessing the risk of pressure sores, and the Morse Scale is used for evaluating a patient's risk of falling, not for determining the level of consciousness.
What is the normal sodium level in the body?
- A. 135 to 145 milliequivalents per liter.
- B. 3 to 5 milliequivalents per liter.
- C. 135 to 145 microequivalents per liter.
- D. 3 to 5 microequivalents per liter.
Correct Answer: A
Rationale: The correct answer is A: 135 to 145 milliequivalents per liter. The normal range for sodium levels in the body is expressed in milliequivalents per liter, not microequivalents. Choice B and D provide a significantly lower range which is not within the normal values for sodium. Choice C incorrectly states 'microequivalents' instead of the correct unit 'milliequivalents'. Therefore, A is the correct answer.
A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?
- A. A client who has an open fracture of the femur
- B. A client who has periorbital ecchymosis
- C. A client who has asymmetrical thorax
- D. A client who has a deep-partial thickness burn on the lower extremities
Correct Answer: C
Rationale: In a triage situation, an asymmetrical thorax suggests a potentially life-threatening condition such as a pneumothorax or hemothorax, requiring immediate attention. This client should be tagged as emergent. Periorbital ecchymosis and deep-partial thickness burns, while concerning, may not indicate an immediate life-threatening situation. An open fracture of the femur, although serious, can be prioritized after addressing emergent cases.