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A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first?
- A. Airway
- B. Blood pressure
- C. Surgical site
- D. Level of consciousness
Correct Answer: A
Rationale: The correct answer is to assess the airway first. Ensuring a clear and patent airway is crucial to maintaining adequate oxygenation and ventilation post-surgery. Assessing the airway takes precedence over other assessments as a compromised airway can lead to hypoxia and respiratory distress. Checking blood pressure, the surgical site, or level of consciousness are important but are secondary to ensuring the airway is clear and the client can breathe effectively.
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The healthcare provider is educating a client about dietary changes to prevent the recurrence of calcium oxalate kidney stones. Which food should the provider advise the client to avoid?
- A. Spinach
- B. Bananas
- C. Chicken
- D. Rice
Correct Answer: A
Rationale: The correct answer is A: Spinach. Spinach is high in oxalate, a compound that can contribute to the formation of calcium oxalate kidney stones. Therefore, advising the client to avoid spinach is crucial in reducing the risk of stone recurrence. Bananas (choice B) are not high in oxalate and do not directly contribute to the formation of calcium oxalate stones, so they do not need to be avoided. Similarly, choices C and D, chicken, and rice, are not typically associated with high oxalate content, making them safe choices and do not need to be avoided specifically to prevent calcium oxalate kidney stones.
When assessing a client's skin turgor, a nurse should:
- A. Grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression
- B. Check skin elasticity on the back of the hand
- C. Press on the skin over the abdomen
- D. Measure skin turgor on the lower leg
Correct Answer: A
Rationale: Correct answer: When assessing a client's skin turgor, a nurse should grasp a fold of the skin on the chest under the clavicle, release it, and note the depth of the impression. This method is reliable for evaluating hydration status as it is less influenced by age-related skin changes or adipose tissue. Choice B, checking skin elasticity on the back of the hand, is not the preferred method for assessing skin turgor. Choice C, pressing on the skin over the abdomen, is not a standard location for assessing skin turgor. Choice D, measuring skin turgor on the lower leg, is not a recommended site for assessing skin turgor in clinical practice.
Which of the following findings contraindicate the use of haloperidol (Haldol) and warrant withholding the dose?
- A. Drowsiness, lethargy, and inactivity
- B. Dry mouth, nasal congestion, and blurred vision
- C. Rash, blood dyscrasias, severe depression
- D. Hyperglycemia, weight gain, and edema
Correct Answer: C
Rationale: The correct answer is C: Rash, blood dyscrasias, and severe depression are serious side effects of haloperidol that necessitate withholding the dose and prompt further evaluation. Rash can indicate an allergic reaction, blood dyscrasias are serious blood disorders that can be life-threatening, and severe depression may worsen with haloperidol use. Choices A, B, and D are incorrect because drowsiness, lethargy, inactivity, dry mouth, nasal congestion, blurred vision, hyperglycemia, weight gain, and edema are common side effects of haloperidol that may not necessarily contraindicate its use but should be monitored and managed appropriately.
When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?
- A. SBAR
- B. SOAP
- C. PIE
- D. DAR
Correct Answer: A
Rationale: The correct answer is A: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating information during shift changes. SBAR provides a clear and concise way for healthcare providers to communicate important details about a patient's condition, ensuring that essential information is effectively transferred between providers. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a method primarily used for documentation in patient charts, not for shift change communication. Choice C, PIE (Problem, Intervention, Evaluation), is a nursing process format for organizing nursing care that focuses on individualized patient care plans, not shift handoff communication. Choice D, DAR (Data, Action, Response), is not a standard format for provider-to-provider handoff communication and is less commonly used in healthcare settings compared to SBAR.
When ethical dilemmas arise, what should newly licensed nurses expect and identify as an ethical dilemma?
- A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment.
- B. A nurse overhears another nurse telling an older adult client that if he doesn't stay in bed, she will have to apply restraints.
- C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.
- D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.
Correct Answer: C
Rationale: An ethical dilemma involves a situation where there are conflicting values or principles that make it difficult to make a clear decision. In the given scenarios, option C best represents an ethical dilemma as the family has conflicting feelings about initiating enteral tube feedings for their terminally ill father. This situation presents a clash between different values and beliefs, making it challenging to reach a resolution. Options A, B, and D do not illustrate conflicting values or principles that characterize an ethical dilemma. Option A describes a nurse's impairment, which is a concern but not a direct ethical dilemma. Option B depicts a potential breach of client autonomy and restraint use, which is an ethical issue but not a true ethical dilemma. Option D involves a client's personal decision regarding a durable power of attorney form, which, although important, does not present conflicting values or principles that define an ethical dilemma.