Nokea
A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client's medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?
- A. Fairness
- B. Responsibility
- C. Risk-taking
- D. Creativity
Correct Answer: B
Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.
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Which toy is most appropriate for an 18-month-old child?
- A. A pull toy
- B. A puzzle with large pieces
- C. A book with large pictures
- D. A doll with small clothes
Correct Answer: A
Rationale: A pull toy is the most appropriate choice for an 18-month-old child. At this age, children are developing their motor skills and coordination, and a pull toy can help with these aspects by encouraging movement and coordination. Puzzle with large pieces (Choice B) may pose a choking hazard for a child of this age due to small parts. While a book with large pictures (Choice C) can be engaging and beneficial for language development, a pull toy is more suitable for promoting physical development in an 18-month-old. A doll with small clothes (Choice D) is not ideal for this age group as small parts can be a choking hazard.
The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?
- A. Providing nail care
- B. Teaching foot care
- C. Making the patient's bed
- D. Determining aspiration risk
Correct Answer: C
Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.
When caring for a client with diarrhea due to shigellosis, what precautions should the nurse implement?
- A. Wear a gown when caring for the client.
- B. Wear gloves only.
- C. Use standard precautions only.
- D. Wear a mask and face shield.
Correct Answer: A
Rationale: The correct answer is to wear a gown when caring for the client. Shigellosis is highly contagious, and contact precautions are essential to prevent the spread of infection. Wearing gloves alone may not provide adequate protection as the client's diarrhea can contain infectious pathogens that can easily spread. Standard precautions include hand hygiene, but specific precautions for shigellosis require wearing a gown to protect against contact with infectious material. Wearing a mask and face shield are not necessary for shigellosis, as the primary mode of transmission is through the fecal-oral route, and these precautions are not indicated for this type of transmission.
A nurse has noticed several occasions in the past week when another nurse on the unit seemed drowsy and unable to focus on the issue at hand. Today, the nurse was found asleep in a chair in the break room not during a break time. Which of the following actions should the nurse take?
- A. Alert the American Nurses Association.
- B. Fill out an incident report.
- C. Report the observations to the nurse manager on the unit.
- D. Leave the nurse alone to sleep.
Correct Answer: C
Rationale: Reporting the observations to the nurse manager is the appropriate action to ensure the safety of the clients and address potential impairment. The nurse manager can take necessary steps to assess the situation and intervene if needed. Alerting the American Nurses Association (Choice A) is not necessary at this stage as the immediate concern is the safety of clients in the unit. Filling out an incident report (Choice B) may be required later, but the priority is to address the issue promptly by involving the immediate supervisor. Leaving the nurse alone to sleep (Choice D) is not a safe option as it does not address the underlying problem of potential impairment and safety concerns; it is essential to address the issue promptly to ensure patient safety.
A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?
- A. Erythema along the path of the vein
- B. Pitting edema at the insertion site
- C. Coolness of the client's left forearm
- D. Pallor of the client's left forearm
Correct Answer: A
Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.