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A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, 'Providing constant care is very stressful and is affecting all areas of my life.' Which of the following actions should the nurse take?
- A. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
- B. Recommend allowing the client to have time alone in their room throughout the day
- C. Discuss methods of how to communicate with the client about resolving problem behaviors
- D. Assist the caregiver to arrange for a daycare program for the client
Correct Answer: D
Rationale: The correct answer is D: Assist the caregiver to arrange for a daycare program for the client. This option addresses the caregiver's concern of stress and the impact on their life by providing respite care. This allows the caregiver to have a break and attend to their own needs while ensuring the client's safety and well-being. It promotes caregiver self-care and prevents burnout.
Option A is incorrect as prescribing antipsychotic medication is not appropriate for caregiver stress. Option B may not address the caregiver's need for a break or support. Option C, while important, focuses on communication strategies rather than providing immediate relief for the caregiver.
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A nurse is caring for a client who is in active labor and notes the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal hypoglycemia
- B. Chorioamnionitis
- C. Fetal anemia
- D. Maternal fever
Correct Answer: C
Rationale: Correct Answer: C (Fetal anemia)
Rationale: Fetal anemia can lead to decreased oxygen delivery to the fetus, causing fetal bradycardia. Anemia reduces the oxygen-carrying capacity of the blood, resulting in the heart working harder to compensate for the decreased oxygen levels, leading to a lower fetal heart rate.
Summary of Incorrect Choices:
A: Maternal hypoglycemia - Unlikely to cause fetal bradycardia directly.
B: Chorioamnionitis - Typically presents with maternal fever and tachycardia, not fetal bradycardia.
D: Maternal fever - Can cause fetal tachycardia, not bradycardia.
A nurse is providing discharge teaching to a client following a total gastrectomy. The nurse should instruct the client about which of the following medications?
- A. Ranitidine
- B. Vitamin B12
- C. Vitamin K
- D. Metoclopramide
Correct Answer: B
Rationale: The correct answer is B: Vitamin B12. Following a total gastrectomy, the client will have reduced intrinsic factor production, leading to vitamin B12 deficiency. Supplementing with Vitamin B12 is crucial to prevent pernicious anemia. Ranitidine (A) is a gastric acid reducer and is not necessary after gastrectomy. Vitamin K (C) is primarily produced in the intestines and is not directly impacted by gastrectomy. Metoclopramide (D) is a prokinetic agent used for gastric motility and is not essential post-gastrectomy.
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
- A. Delegate tasks to the AP
- B. Determine goals of the day.
- C. Develop an hourly time frame for tasks
- D. Schedule daily activities
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step to managing time effectively as it helps prioritize tasks and establish a clear direction for care delivery. By setting goals, the nurse can focus on important tasks, delegate appropriately, and allocate time efficiently.
A: Delegating tasks to the AP can come after determining goals to ensure tasks are aligned with priorities.
C: Developing an hourly time frame for tasks can be done once goals are established to create a detailed schedule.
D: Scheduling daily activities is important but should be based on the goals set for the day.
In summary, determining goals of the day is the initial step in time management as it provides a framework for prioritizing tasks and organizing activities efficiently.
A nurse is conducting an initial assessment of a client and notices a discrepancy between the client's current IV infusion and the information received during the shift report. Which of the following actions should the nurse take?
- A. Contact the charge nurse to see if the prescription was changed
- B. Complete an incident report and place it in the client's medical record
- C. Submit a written warning for the nurse involved in the incident
- D. Compare the current infusion with the prescription in the client's medication record
Correct Answer: D
Rationale: The correct answer is D: Compare the current infusion with the prescription in the client's medication record. This is the best course of action as it allows the nurse to verify the accuracy of the IV infusion against the prescribed treatment plan. By cross-referencing the current infusion with the prescription in the client's medication record, the nurse can identify any discrepancies and take appropriate actions to ensure the client's safety and well-being.
Choice A is incorrect because contacting the charge nurse may not provide the necessary information to verify the accuracy of the IV infusion. Choice B is incorrect as completing an incident report is premature without first verifying the discrepancy. Choice C is inappropriate and punitive without a proper investigation. Choices E, F, and G are not provided in the question, so they are irrelevant.
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Maintain calorie intake at 1,500 per day
- B. Provide a low-protein, high-carbohydrate diet.
- C. Keep a calorie count for foods and beverages.
- D. Schedule meals at 6-hr intervals
Correct Answer: C
Rationale: The correct answer is C: Keep a calorie count for foods and beverages. For a client with major burn injuries, accurate monitoring of calorie intake is crucial to support nutritional requirements for wound healing and metabolic demands. This intervention allows the nurse to adjust the diet as needed to meet the client's energy needs. Choice A is incorrect as calorie intake requirements may vary based on individual needs. Choice B is incorrect as a high-protein diet is essential for wound healing in burn patients. Choice D is incorrect as frequent, smaller meals are typically recommended for burn patients to support healing and prevent muscle breakdown.