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A nurse on a med-surg unit is caring for a group of clients with the assistance of an LPN and an AP. Which of the following tasks should the nurse assign to the LPN?
- A. Reinforce dietary teaching with a client who has heart disease.
- B. Obtaining a urine specimen from an older adult client
- C. Providing postmortem care for a client who has just died.
- D. Accompanying a client who just had a wound debridement to PT.
Correct Answer: A
Rationale: The correct answer is to reinforce dietary teaching with a client who has heart disease. This task falls within the LPN's scope of practice as they can provide education and support related to nutrition. Obtaining a urine specimen (Choice B) is typically performed by nursing assistants. Providing postmortem care (Choice C) is a sensitive task usually performed by registered nurses. Accompanying a client to physical therapy (Choice D) is often done by nursing assistants or other supportive staff.
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Which of the following is the best way to improve nursing's image?
- A. Uniforms should reflect your professionalism.
- B. Introduce yourself with your full name.
- C. Understand the essence of professional behavior in your practice.
- D. Take every opportunity to speak to the public about nursing.
Correct Answer: D
Rationale: The correct answer is D because taking every chance to engage with the public about nursing allows for the improvement of nursing's image and the promotion of the profession. Choice A is incorrect as uniforms should reflect professionalism rather than personality. Choice B is not directly related to improving nursing's image. Choice C, while important, does not directly address improving the image of nursing through public engagement.
The wound irrigation process cleanses the wound and:
- A. Reduces the potential pain in the wound region or area.
- B. Stops the spread of infection by creating a 'clean' area.
- C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
- D. Allows for the introduction of medications in solution form.
Correct Answer: D
Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.
What is the most common cause of HHNS?
- A. Insulin overdose
- B. Removal of the adrenal gland
- C. Undiagnosed, untreated hyperpituitarism
- D. Undiagnosed, untreated diabetes mellitus
Correct Answer: D
Rationale: The correct answer is D: Undiagnosed, untreated diabetes mellitus. Hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is most commonly caused by undiagnosed and untreated diabetes mellitus. Insulin overdose (Choice A) is not a typical cause of HHNS; it is more related to hypoglycemia. Removal of the adrenal gland (Choice B) can lead to adrenal insufficiency but is not a common cause of HHNS. Undiagnosed, untreated hyperpituitarism (Choice C) is not a usual cause of HHNS; it is more related to pituitary hormone imbalances rather than hyperglycemia.
A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
- A. Remove the restraints from the client's wrists
- B. Review the chart for nonrestraint alternatives for agitation
- C. Speak with the AP about the incident
- D. Inform the unit manager of the incident
Correct Answer: A
Rationale: The correct action for the nurse to take first is to remove the restraints from the client's wrists. Restraints should not be applied without a prescription due to the risk of harm to the client. Removing the restraints promptly is a priority to ensure the client's safety. Reviewing nonrestraint alternatives, speaking with the AP, and informing the unit manager can follow after ensuring the client's immediate safety by removing the restraints.
A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?
- A. Offer to provide care for his clients while he takes a break
- B. Advise him to complete less time-consuming tasks first
- C. Ask other staff members to take over some of his tasks
- D. Recommend that he take time to plan at the beginning of his shift
Correct Answer: D
Rationale: The correct intervention is to recommend that the new nurse takes time to plan at the beginning of his shift. Planning ahead can help improve time management and focus. Option A is not ideal as it does not address the root cause of the issue and may not promote independence. Option B may not be effective if the nurse is struggling with time management in general. Option C involves shifting responsibilities to others without addressing the new nurse's need for improvement in managing his workload, which should be the priority.