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A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory results would be a priority for the nurse to report to the provider?
- A. BUN 21 mg/dL (10 to 20 mg/dL)
- B. Potassium 5.8 mEq/L (3.5 to 5 mEq/L)
- C. Creatinine 1.4 mg/dL (0.5 to 1.1 mg/dL)
- D. Sodium 132 mEq/L (136 to 145 mEq/L)
Correct Answer: B
Rationale: The correct answer is B: Potassium 5.8 mEq/L. In hypovolemia, there is a decrease in blood volume leading to electrolyte imbalances. Potassium levels outside the normal range can be life-threatening, causing cardiac arrhythmias. Therefore, a potassium level of 5.8 mEq/L is a priority to report to the provider for prompt intervention.
Rationale for why the other choices are incorrect:
A: BUN within the normal range. It may indicate dehydration but not immediately life-threatening.
C: Creatinine slightly elevated, indicating kidney function impairment but not as critical as potassium imbalance.
D: Sodium within acceptable range, not an immediate concern in hypovolemia.
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A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to
- A. check glucose levels before, during, and after swimming.
- B. delay eating the noon meal until after swimming.
- C. increase the morning dose of neutral protamine Hagedorn (NPH) insulin.
- D. time the morning insulin injection so that the peak occurs while swimming.
Correct Answer: A
Rationale: The correct answer is A because the patient with type 1 diabetes should check glucose levels before, during, and after swimming to monitor for fluctuations and adjust insulin or food intake accordingly. This allows for better glycemic control and prevents hypoglycemia or hyperglycemia during and after swimming.
Choice B is incorrect because delaying eating can lead to hypoglycemia during swimming due to increased insulin action without adequate glucose intake. Choice C is incorrect as increasing NPH insulin dose without monitoring glucose levels can result in hypoglycemia during exercise. Choice D is incorrect because timing the insulin injection for peak action while swimming can also lead to hypoglycemia if glucose levels are not monitored.
Which of the following is a characteristic of a well-written goal?
- A. Goals should be vague
- B. Goals should be unrealistic
- C. Goals need to be measurable, realistic, and achievable
- D. Goals should be easy to achieve
Correct Answer: C
Rationale: The correct answer is C because well-written goals need to be specific, measurable, achievable, relevant, and time-bound (SMART). Measurable goals allow for tracking progress, realistic goals are attainable, and achievable goals are within reach. Vague goals (A) lack clarity, unrealistic goals (B) may lead to frustration, and goals that are too easy to achieve (D) do not challenge individuals to grow and improve. Therefore, option C is the best choice for a well-written goal.
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.
How does decision making differ from problem solving?
- A. Decision making always involves selecting from a set of alternatives.
- B. Problem solving always involves selecting one of several alternatives.
- C. Problem solving never involves decision making.
- D. Decision making always involves solving a problem.
Correct Answer: A
Rationale: The correct answer is A because decision making involves evaluating different options and choosing the best one among them, while problem solving focuses on finding a solution to a specific issue or challenge. Therefore, decision making requires selecting from a set of alternatives, which is not always the case in problem solving.
Choice B is incorrect because problem solving may not always involve selecting one of several alternatives; it can also involve finding a creative or innovative solution.
Choice C is incorrect because decision making can be part of problem solving when determining the best course of action.
Choice D is incorrect because decision making does not always involve solving a problem; it can also involve making choices in various situations.
In determining a way to make shift change more effective for the nurse and the client, a hospital implemented a course of action. After a week of implementation, the decision was deemed inappropriate. What step of Roger's diffusion of innovations is this?
- A. Confirmation
- B. Implementation
- C. Knowledge
- D. Persuasion
Correct Answer: A
Rationale: The correct answer is A: Confirmation. In Roger's diffusion of innovations theory, Confirmation is the stage where individuals evaluate the decision to adopt or reject an innovation after trying it out. In this scenario, the hospital implemented a course of action for shift change, and after a week, it was deemed inappropriate, indicating that the decision reached the Confirmation stage.
Summary:
- B: Implementation is incorrect as the hospital had already implemented the course of action.
- C: Knowledge is incorrect as this stage involves acquiring information about the innovation.
- D: Persuasion is incorrect as it focuses on influencing individuals to adopt the innovation, which is not the case in this scenario.