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A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the
patient has been away from the nursing unit for 2 hours, missing the lunch delivery while
awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to
- A. save the lunch tray for the patient’s later return to the unit
- B. ask that diagnostic testing area staff to start a 5% dextrose IV
- C. send a glass of milk or orange juice to the patient in the diagnostic testing area
- D. request that if testing is further delayed, the patient be returned to the unit to eat.
Correct Answer: D
Rationale: The correct answer is D. It is essential to maintain the patient's blood glucose levels to prevent hypoglycemia. Since the patient missed lunch, returning them to the unit to eat ensures timely access to food for glycemic control. This action addresses the immediate need for nutrition and glucose intake.
A: Saving the lunch tray is not immediate and does not address the patient's current hypoglycemia risk.
B: Starting a dextrose IV is an option for severe hypoglycemia, not for preventing it in this scenario.
C: Sending milk or orange juice may help raise blood sugar but does not address the need for a complete meal to prevent hypoglycemia.
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A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour. Which of the following actions should the nurse take next?
- A. Document the surgeon's instructions in the client's medical record.
- B. Complete an incident report.
- C. Consult the charge nurse.
- D. Notify the nursing manager.
Correct Answer: D
Rationale: The correct answer is D: Notify the nursing manager. The nurse should escalate the situation to the nursing manager because the surgeon's instructions may not be appropriate for a client in hemorrhagic shock. The nurse needs to advocate for the client's safety and ensure prompt and appropriate intervention. Consulting the charge nurse may not be sufficient, and documenting the instructions or completing an incident report does not address the immediate need for proper medical intervention.
Which of the following is a potential benefit of social media?
- A. Sharing the fun side of nursing by posting a video of nurses singing and dancing in the hallways of the hospital while on duty
- B. Connecting with clients to keep up with their health status
- C. Connecting with the public to encourage healthy behaviors
- D. Sharing pictures of interesting clinical experiences with friends
Correct Answer: C
Rationale: The correct answer is C because connecting with the public to encourage healthy behaviors is a potential benefit of social media. It allows healthcare professionals to reach a wider audience and promote positive health practices. Choice A is inappropriate as it may violate patient confidentiality. Choice B is more focused on individual clients rather than a broader public health approach. Choice D may also risk violating patient privacy and lacks the educational aspect of promoting healthy behaviors.
Which of the following is considered voluntary turnover?
- A. Desire to leave
- B. Termination
- C. Forced resignation
- D. Floating
Correct Answer: A
Rationale: The correct answer is A: Desire to leave. Voluntary turnover occurs when an employee chooses to leave the organization. This choice could be due to personal reasons, career advancement, or dissatisfaction with the current job. Termination (B) is involuntary, forced resignation (C) is also not voluntary as it involves external pressure, and floating (D) is not a recognized term in the context of turnover. Therefore, A is the correct choice for voluntary turnover.
A unit director at a local hospital knows even leadership may face ethical dilemmas. Which of the following should the director take into consideration when dealing with an employee who is incompetent?
- A. The situation should be tolerated for as long as possible because of the amount of time and paperwork required to terminate an incompetent nurse.
- B. Incompetence only impacts the individual nurse.
- C. The director should follow her institution’s formal process for reporting and handling practices that jeopardize patient safety.
- D. Most nurse practice acts direct how to handle incompetent nurses.
Correct Answer: C
Rationale: The correct answer is C because the director should follow the institution's formal process for reporting and handling practices that jeopardize patient safety. This is crucial to maintain high standards of patient care and ensure accountability. Choice A is incorrect as tolerating incompetence can lead to serious consequences for patient safety. Choice B is incorrect as incompetence can impact patient outcomes and overall quality of care. Choice D is incorrect as nurse practice acts may provide guidelines but the institution's specific process should be followed to address incompetence effectively.
Which of the following conditions would be well suited to the use of a nursing critical pathway?
- A. Foreign object in the ear
- B. Fever of unknown origin
- C. Hip replacement surgery
- D. Bacterial infection acquired in a foreign country
Correct Answer: C
Rationale: The correct answer is C: Hip replacement surgery. Nursing critical pathways are designed for standardized, evidence-based care plans for specific medical conditions or procedures. Hip replacement surgery is a well-defined process with clear guidelines for pre-op, intra-op, and post-op care, making it suitable for a critical pathway. Foreign object in the ear (A) requires immediate intervention but doesn't involve a complex care pathway. Fever of unknown origin (B) requires extensive diagnostic workup, making it less suitable for a standardized pathway. Bacterial infection acquired in a foreign country (D) may have variable presentations and treatment, not fitting a standardized pathway.