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A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following should the nurse take first?
- A. Refer the AP to the facility procedure manual
- B. Demonstrate the proper client transfer technique for the AP
- C. Instruct the AP to request assistance when unsure about a task
- D. Help the AP assist the client with the transfer
Correct Answer: D
Rationale: The correct first action for the nurse is to ensure the safety of the client by immediately intervening to help the AP with the transfer. This hands-on assistance can prevent any potential harm to the client. Referring the AP to the facility procedure manual (Choice A) might take time and delay the necessary immediate action. Demonstrating the proper technique (Choice B) can be done after ensuring the client's safety. Instructing the AP to request assistance (Choice C) is not the most urgent step when a client's safety is at risk.
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Which statement about glaucoma is true and accurate?
- A. Acute angle-closure glaucoma is an ocular emergency.
- B. Acute angle-closure glaucoma leads to the loss of peripheral vision and tunnel vision.
- C. Primary open-angle glaucoma leads to eye pain, nausea, and vomiting, blurry vision, and halos.
- D. Bubbles are implanted to protect the retina from glaucoma.
Correct Answer: A
Rationale: The correct answer is A: 'Acute angle-closure glaucoma is an ocular emergency.' Acute angle-closure glaucoma is indeed considered an ocular emergency that requires immediate attention to prevent vision loss. Choice B is incorrect because acute angle-closure glaucoma commonly presents with symptoms like severe eye pain, headache, blurred vision, and halos around lights. Choice C is incorrect as these symptoms are more indicative of acute angle-closure glaucoma rather than primary open-angle glaucoma. Choice D is incorrect since bubbles are not typically used to protect the retina from glaucoma; treatment usually involves medications, laser therapy, or surgery to manage intraocular pressure.
Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal?
- A. The client will be very thirsty.
- B. The client will complain of nausea.
- C. The client will need to urinate.
- D. The client will have moist skin.
Correct Answer: D
Rationale: The correct answer is D. In this scenario, since Ben took his insulin but forgot to eat, he is at risk of developing hypoglycemia. Moist skin is a sign of hypoglycemia, which can occur when blood sugar levels drop too low. Thirstiness (choice A) is more commonly associated with hyperglycemia (high blood sugar levels). Nausea (choice B) and frequent urination (choice C) are not typical immediate signs of hypoglycemia caused by missing a meal after insulin administration.
Your client is adversely affected with fever, night sweats, occult hematuria, tenderness of the spleen, and Osler's nodes. What disorder would you most likely suspect?
- A. Tuberculosis
- B. AIDS/HIV
- C. Pericarditis
- D. Endocarditis
Correct Answer: D
Rationale: The client is likely suffering from endocarditis based on the symptoms described. Endocarditis is characterized by fever, night sweats, hematuria, splenomegaly (tenderness of the spleen), and Osler's nodes (painful nodules on the pads of the fingers or toes). While tuberculosis and AIDS/HIV can present with some similar symptoms, the presence of Osler's nodes is more specific to endocarditis. Pericarditis typically presents with chest pain, not the combination of symptoms seen in this case.
Select the criteria that is accurately paired with its indication of birth weight or gestational age.
- A. Low birth weight: The neonate's weight is less than 1,500 g at the time of delivery.
- B. Appropriate for gestational age: The neonate's weight ranges from the 10th to the 90th percentile.
- C. Large for gestational age: The neonate's weight is above the 99th percentile.
- D. Small for gestational age: The neonate's weight is below the 20th percentile.
Correct Answer: B
Rationale: Appropriate for gestational age (AGA) indicates a neonate's weight ranging from the 10th to the 90th percentile. This range signifies that the baby's weight is within the normal range for their gestational age. Choices A, C, and D provide inaccurate information about the criteria and do not correctly correspond to the indicated birth weight or gestational age. Low birth weight typically refers to a weight below 2,500 g, large for gestational age above the 90th percentile, and small for gestational age below the 10th percentile.
Which healthcare-associated infection poses the greatest risk for patients?
- A. Pneumonia
- B. Catheter-related infections
- C. Intravenous line infections
- D. C. difficile
Correct Answer: B
Rationale: Catheter-related infections pose the greatest risk for patients in healthcare settings. Catheters are invasive devices that can introduce pathogens directly into the bloodstream, leading to severe infections. Pneumonia, intravenous line infections, and C. difficile infections are serious concerns as well, but catheter-related infections are particularly risky due to the direct access they provide for pathogens to enter the body.