Nokea
A nurse is using active listening as a form of therapeutic communication when:
- A. She uses humor to put the client at ease in a situation
- B. She restates what the client said in slightly different words
- C. She uses eye contact and maintains an open stance while the client is talking
- D. She provides personal information to show the client she can relate to him
Correct Answer: C
Rationale: The correct answer is C because using eye contact and maintaining an open stance while the client is talking demonstrates active listening. Eye contact shows attentiveness and respect, while an open stance conveys empathy and receptiveness. This non-verbal communication encourages the client to feel heard and understood, fostering a therapeutic relationship.
Choice A is incorrect because using humor may not always align with the client's feelings or be perceived as appropriate. Choice B is incorrect as restating what the client said is a form of paraphrasing, not active listening. Choice D is incorrect because providing personal information can shift the focus away from the client's needs and may breach professional boundaries.
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Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?
- A. Call the supervisor and file a complaint against the physical therapy department
- B. Contact the physician to notify him that the orders were not carried out
- C. Assess the client's activity level by assisting with ambulation using a gait belt
- D. Contact the physical therapy department again and repeat the order
Correct Answer: D
Rationale: The most appropriate action for the nurse in this scenario is to contact the physical therapy department again and repeat the order (Choice D). This is the correct answer because it directly addresses the issue of the consult not being completed within a reasonable timeframe. By contacting the department again, the nurse ensures that the order is not overlooked or forgotten. This action shows proactive communication and follow-up to expedite the process and ensure the client receives the necessary care in a timely manner.
The other choices are incorrect:
A: Calling the supervisor and filing a complaint is premature without first attempting to resolve the issue directly with the department.
B: Contacting the physician is not the nurse's role in this situation. The focus should be on coordinating with the appropriate department.
C: Assessing the client's activity level is important but does not address the primary issue of the physical therapy consult not being completed.
Overall, choice D is the most appropriate course of action in this scenario.
A nurse is asked to perform a task that she believes is outside her scope of practice. What is the appropriate response to this issue?
- A. Contact the state board of nursing licensure to report the offense
- B. Review the state scope of practice standards for nurses
- C. Ask another nurse to perform the task to learn the procedure
- D. Contact the house supervisor to make the decision on whether the nurse should perform the task
Correct Answer: B
Rationale: The correct answer is B: Review the state scope of practice standards for nurses. This is the appropriate response as it allows the nurse to understand her legal boundaries and responsibilities. By reviewing the state scope of practice standards, the nurse can ensure she is acting within the limits of her licensure and avoid potential legal or ethical issues.
Choice A is incorrect because reporting the offense to the state board of nursing licensure should not be the initial response without first verifying the scope of practice standards. Choice C is incorrect as it does not address the issue of the nurse operating outside her scope of practice. Choice D is incorrect as the house supervisor may not have the necessary knowledge of the nurse's scope of practice.
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
- A. Pulmonary embolectomy
- B. Vena caval interruption
- C. Increasing the coumadin therapy to achieve an INR of 3-4
- D. Thrombolytic therapy
Correct Answer: B
Rationale: The correct answer is B: Vena caval interruption. In this scenario, the client has a history of recurrent pulmonary embolism, indicating a high risk for further episodes. Vena caval interruption, such as with an inferior vena cava filter, is a preventive measure to reduce the risk of pulmonary embolism recurrence by trapping blood clots before they reach the pulmonary circulation. This intervention is indicated when anticoagulation alone is not sufficient to prevent further emboli. Pulmonary embolectomy (A) is a surgical procedure to remove a clot from the pulmonary artery and is typically reserved for massive, life-threatening embolisms. Increasing coumadin therapy (C) to achieve a higher INR may increase bleeding risk without necessarily preventing future emboli. Thrombolytic therapy (D) is reserved for acute, large emboli causing hemodynamic instability.
A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?
- A. Ask the client to undress to assess for injuries
- B. Take the client into a private room
- C. Notify the police to file a report
- D. Notify the house supervisor to keep security on alert
Correct Answer: B
Rationale: The correct answer is B: Take the client into a private room. This is the most appropriate action because it ensures the client's privacy and confidentiality, which is crucial in cases of suspected domestic violence. By placing the client in a private room, the nurse can establish a safe and secure environment for the client to disclose sensitive information and receive proper care. This approach also helps to build trust with the client and allows for a thorough assessment of injuries without compromising the client's dignity.
Choice A is incorrect because asking the client to undress immediately may further traumatize the client and violate her privacy. Choice C is not the nurse's immediate responsibility; the priority is to ensure the client's safety and well-being. Choice D is also not the most appropriate action as it does not directly address the client's immediate needs.
At the beginning of the shift, a nurse receives report for her daily assignment. Which of the following situations should the nurse give first priority?
- A. A diabetic client with a blood glucose level of 195 mg/dL
- B. A family member of an elderly client who has questions
- C. A client with COPD with an oxygen saturation of 84%
- D. A client who requires assistance to use the bathroom
Correct Answer: C
Rationale: The correct answer is C: A client with COPD with an oxygen saturation of 84%. Oxygen saturation below 90% is considered critical, indicating hypoxemia in a client with COPD. Priority is given to critical physiological needs to avoid potential respiratory distress or failure. Choices A, B, and D are important but do not pose immediate life-threatening risks. The diabetic client with a blood glucose level of 195 mg/dL can be managed with insulin administration. The family member's questions can be addressed after addressing immediate client needs. The client who requires assistance to use the bathroom can be attended to once the critical client's needs are addressed. Prioritizing based on physiological urgency ensures client safety.