Nokea
A nurse is talking with another nurse on the unit and smells alcohol on her breath. Which of the following actions should the nurse take?
- A. Confront the nurse about the suspected alcohol use.
- B. Inform another nurse on the unit about the suspected alcohol use.
- C. Ask the nurse to finish administering medications and then go home.
- D. Notify the nursing manager about the suspected alcohol use.
Correct Answer: A
Rationale: Confronting the nurse about the suspected alcohol use is the most appropriate action in this situation. It is essential to address the issue directly and express concerns about patient safety and potential impairment. By addressing the situation promptly, the nurse can potentially prevent harm and provide support to the colleague in need.
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A healthcare professional realizes that the wrong medication has been administered to a client. Which of the following actions should the healthcare professional take first?
- A. Notify the provider.
- B. Report the incident to the healthcare facility's manager.
- C. Monitor vital signs.
- D. Fill out an incident report.
Correct Answer: C
Rationale: In a situation where the wrong medication has been administered to a client, the immediate priority is to assess and monitor the client's vital signs to identify any adverse effects of the incorrect medication. This action takes precedence over notifying the provider, reporting the incident, or filling out an incident report. Monitoring vital signs allows for timely recognition and intervention if the client experiences any negative reactions to the wrong medication, ensuring their safety and well-being.
While teaching a newly hired nurse about varicella, a nurse in a pediatric clinic should include which of the following information?
- A. Children who have varicella are contagious until vesicles are crusted.
- B. Children who have varicella should receive the varicella (chickenpox) vaccine.
- C. Children who have varicella should be placed in airborne precautions.
- D. Children who have varicella are contagious 1-2 days before the rash appears.
Correct Answer: A
Rationale: Children with varicella (chickenpox) are contagious until all vesicles are crusted over. The contagious period starts 1-2 days before the rash appears and continues until all lesions are dried and crusted. It is important to educate healthcare providers about the contagious period to prevent the spread of the virus to susceptible individuals.
When caring for a client who speaks a language different from their own, what action should the nurse take?
- A. Request an interpreter of a different sex from the client.
- B. Request a family member or friend to interpret information for the client.
- C. Direct attention toward the interpreter when speaking to the client.
- D. Review the facility policy about the use of an interpreter.
Correct Answer: D
Rationale: When caring for a client who speaks a different language, it is essential for the nurse to review the facility policy about the use of an interpreter. Using a professional interpreter ensures accurate communication and protects the client's confidentiality. Requesting an interpreter of a specific sex or relying on family members or friends can lead to miscommunication or breaches of confidentiality. Directing attention towards the interpreter helps facilitate communication but does not address the need for a professional interpreter as per facility policy.
During a shift change, a nurse is receiving a report for an adult female client who is postoperative. Which of the following client information should the nurse report?
- A. High platelets
- B. Hypertension
- C. Lower platelets
- D. High temperatures
Correct Answer: C
Rationale: Lower platelets can indicate a potential risk of bleeding in a postoperative client. Thrombocytopenia, or low platelet count, can lead to increased bleeding tendencies and should be promptly reported to the healthcare team for appropriate management. Monitoring platelet levels is crucial in postoperative care to prevent complications related to inadequate clotting ability.
When providing discharge teaching for a group of clients, a nurse should recommend a referral to a dietitian for which client?
- A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
- B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
- C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
- D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'
Correct Answer: B
Rationale: The correct answer is the client who has gout and states, 'I can continue to eat anchovies on my pizza.' Gout is a condition that requires dietary modifications to manage symptoms. Anchovies are high in purines, which can exacerbate gout symptoms. Therefore, a referral to a dietitian is essential to provide appropriate dietary guidance for a client with gout. Clients on warfarin may need to monitor their vitamin K intake, particularly from foods like spinach. Clients taking spironolactone should be cautious about potassium-rich foods. Clients with osteoporosis should be educated on the proper administration of calcium supplements but do not necessarily need a dietitian referral for this specific statement.