Nokea
What type of injury is associated with acute hyphema?
- A. orthopedic
- B. eye
- C. insect sting or snakebite
- D. gynecological trauma
Correct Answer: B
Rationale: Acute hyphema is associated with an eye injury, typically resulting from blunt trauma. The presence of blood in the anterior chamber of the eye causes a half-moon appearance or a horizontal line across the globe when the client is upright. Choices A, C, and D are incorrect because acute hyphema is not related to orthopedic injuries, insect stings, snakebites, or gynecological trauma.
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A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a 'slow code' and let the client 'rest in peace' if she stops breathing. How should the nurse respond?
- A. Telling the health care provider that the client would probably want to die in peace
- B. Telling the health care provider that if the client stops breathing, the health care provider will be called before any other actions are taken
- C. Telling the health care provider that all of the nurses on the unit agree with this plan
- D. Telling the health care provider that 'slow codes' are not acceptable
Correct Answer: D
Rationale: The nurse may not violate a family's request regarding the client's treatment plan. A 'slow code' is not acceptable, and the nurse should state this to the health care provider. The definition of a 'slow code' varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are inappropriate: Option A is speculative and does not address the issue directly; Option B does not challenge the unethical practice of a 'slow code'; Option C is irrelevant and does not address the ethical concerns raised by the health care provider's request.
When documenting in the client’s record, what type of information should be recorded?
- A. educated predictions of outcomes
- B. personal opinions
- C. objective information
- D. subjective information
Correct Answer: C
Rationale: When documenting in a client's record, it is crucial to record objective information. Objective information is factual, based on observations and measurable data. This type of information is essential for accurate and effective communication among healthcare professionals involved in the client's care. Choices A and B, educated predictions of outcomes and personal opinions, are subjective in nature and may not provide an accurate representation of the client's condition. Choice D, subjective information, includes personal feelings, interpretations, and opinions, which are not ideal for documentation as they can be biased and unreliable.
The nurse manager of a quality improvement program asks a nurse in the neurological unit to conduct a retrospective audit. Which action should the auditing nurse plan to perform in this type of audit?
- A. Checking the crash cart to ensure that all needed supplies are readily available in case of an emergency
- B. Checking the documentation written by a new nursing graduate on her assigned clients at the end of the shift
- C. Reviewing neurological assessment checklists for all clients on the unit to ensure that these assessments are being conducted as prescribed
- D. Obtaining the assigned medical record from the hospital's medical record room to review documentation made during a client's hospital stay
Correct Answer: D
Rationale: Quality improvement, also known as performance improvement, focuses on processes contributing to client safety and care outcomes. Retrospective audits involve reviewing medical records after discharge for compliance with standards. Concurrent audits assess staff compliance during a client's stay. Therefore, obtaining the medical record from the hospital's record room for review is crucial in a retrospective audit. Options A, B, and C are more suited for concurrent audits as they involve real-time assessment during a client's stay.
An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?
- A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- B. The client will maintain a blood glucose level within normal range limits today.
- C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct Answer: C
Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.
The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?
- A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
- B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
- C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
- D. Proceed with transporting the client to the operating room without obtaining informed consent.
Correct Answer: D
Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.