Nokea
A nurse is required to float to another unit within the hospital where he is asked to care for a client on a ventilator. The nurse is uncomfortable with this assignment, as he has not had a ventilated client since nursing school. What is the nurse's most appropriate response?
- A. Explain to the nursing supervisor the level of discomfort and ask for a different assignment
- B. State that the client's needs are outside the nurse's scope of practice and request a different assignment
- C. Accept the assignment, asking for help when necessary
- D. Request to return to the home unit and send another nurse who can perform the job
Correct Answer: A
Rationale: The correct answer is A: Explain to the nursing supervisor the level of discomfort and ask for a different assignment. This is the most appropriate response because the nurse is being transparent about their discomfort and seeking a solution to ensure quality care for the client. By communicating concerns, the nurse can potentially be given a more suitable assignment or receive additional training. Option B is incorrect as it is important for nurses to continuously learn and adapt to new situations within their scope of practice. Option C is not ideal as the nurse should not take on a task they are uncomfortable with without proper support. Option D is not the best choice as it does not address the issue directly with the supervisor.
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Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
- A. Taking a health history and performing a physical exam prior to the procedure
- B. Instructing the client about how to care for his colostomy stoma
- C. Developing goals that state the client will ambulate three times a day
- D. Determining that the client may need more support at home after dismissal
Correct Answer: B
Rationale: The correct answer is B. Instructing the client about how to care for his colostomy stoma is an example of the intervention phase as it involves providing specific guidance to the client on post-operative care. This intervention directly addresses the client's needs post-colostomy and helps promote optimal healing and adjustment.
Choice A is part of the assessment phase, which occurs before the intervention phase. Choice C involves goal-setting, which is part of the planning phase. Choice D pertains to discharge planning, which is part of the evaluation phase.
In summary, Choice B is the correct answer because it aligns with the intervention phase of the nursing care plan, focusing on providing necessary education and support to the client regarding colostomy care.
At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?
- A. A diabetic client with a blood glucose level of 195 mg/dL
- B. A family member of an elderly client who has questions
- C. A client with COPD with an oxygen saturation of 84%
- D. A client who requires assistance to use the bathroom
Correct Answer: C
Rationale: The correct answer is C: A client with COPD with an oxygen saturation of 84%. Oxygen saturation below 90% is considered critical, indicating hypoxemia in a client with COPD. Priority is given to critical physiological needs to avoid potential respiratory distress or failure. Choices A, B, and D are important but do not pose immediate life-threatening risks. The diabetic client with a blood glucose level of 195 mg/dL can be managed with insulin administration. The family member's questions can be addressed after addressing immediate client needs. The client who requires assistance to use the bathroom can be attended to once the critical client's needs are addressed. Prioritizing based on physiological urgency ensures client safety.
Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?
- A. Collect and organize documents for the client's medical record
- B. Prepare the client's identification bracelet
- C. Identify pertinent health history data and current needs and limitations
- D. Gather the client's valuables and secure them in a locked container
Correct Answer: C
Rationale: The correct answer is C because identifying pertinent health history data and current needs and limitations is crucial in developing an individualized care plan for the stroke patient. This data helps determine the appropriate interventions and therapies needed for the client's recovery. Collecting and organizing documents (choice A) can be important but not the primary action. Preparing an identification bracelet (choice B) and gathering valuables (choice D) are important tasks but not the immediate priority upon admission.
When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
- A. 86/162
- B. irregular and high
- C. 162/86
- D. normal for people of all ages
Correct Answer: C
Rationale: The correct answer is C: 162/86. The first sound heard corresponds to the systolic pressure (top number) and the second sound heard corresponds to the diastolic pressure (bottom number). Therefore, the blood pressure is documented as systolic/diastolic. In this case, the first sound at 162 indicates the systolic pressure, and the second sound at 86 indicates the diastolic pressure. Alternatives A (86/162) is incorrect as systolic pressure always comes first. B (irregular and high) is incorrect as the blood pressure values are within normal range. Option D (normal for people of all ages) is incorrect because the blood pressure should be documented as per standard practice, regardless of age.
At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
- A. A 91-year-old man who needs help eating breakfast
- B. An 86-year-old man who has been incontinent in his bed
- C. An 82-year-old woman who needs IV antibiotics
- D. A 75-year-old man who is recovering from an injury and needs an ice pack
Correct Answer: C
Rationale: The correct answer is C: An 82-year-old woman who needs IV antibiotics. Checking on this client first is crucial because IV antibiotics are time-sensitive and require proper administration to ensure the effectiveness of treatment. Delaying or missing a dose can have serious consequences for the client's health. The other choices, while important, can be prioritized after attending to the client needing IV antibiotics. A: The 91-year-old man needing help eating breakfast can wait a bit longer. B: The 86-year-old man who has been incontinent can be addressed after the client needing IV antibiotics. D: The 75-year-old man recovering from an injury and needing an ice pack can also be attended to after the client requiring IV antibiotics.