Nokea
A nurse working on a med-surg unit is managing the care of four clients. The nurse should schedule an interdisciplinary conference for which of the following clients?
- A. A client who is at risk for pressure ulcers and has an albumin level of 4.2 g/dL
- B. A client with type 1 DM who uses an insulin pump
- C. A client who is receiving heparin and has an aPTT of 34 seconds
- D. A client with orthostatic hypotension receiving IV fluids
Correct Answer: C
Rationale: The nurse should schedule an interdisciplinary conference for a client who is receiving heparin and has an aPTT of 34 seconds to ensure comprehensive care coordination. In this case, the need for a conference may be to discuss potential adjustments in heparin therapy, monitor for adverse effects, or ensure proper anticoagulation levels. Choices A, B, and D do not specifically indicate the need for interdisciplinary collaboration related to the client's condition or treatment. Therefore, they are not the priority for scheduling an interdisciplinary conference.
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Which of the following is expected to be most likely true in the near future?
- A. Quality improvement projects will decline due to cost-cutting measures.
- B. Alternative and complementary approaches will gain acceptance in medical practice.
- C. Care will primarily shift away from the hospital setting.
- D. Increased focus on care transitions will involve nursing.
Correct Answer: D
Rationale: In the near future, there will be an increased focus on care transitions involving nursing. This means that nurses will play a crucial role in preparing patients for transitions between different care settings, ensuring continuity and quality of care. Choice A is incorrect because quality improvement projects are essential and are not expected to decline. Choice B is incorrect as alternative and complementary approaches are increasingly being integrated into medical practice. Choice C is incorrect as there is a growing trend towards providing care in community settings and homes, moving away from primarily hospital-based care.
Which technique or method is used to determine whether or not the patient has an irregular pulse?
- A. Apical pulse
- B. Inspection
- C. Auscultation
- D. Percussion
Correct Answer: A
Rationale: An apical pulse check is used to determine if the patient has an irregular pulse. The apical pulse is located at the point of maximal impulse (PMI) and is assessed using a stethoscope. Choice B, inspection, involves visual examination and is not used to assess pulse irregularities. Choice C, auscultation, involves listening to internal sounds using a stethoscope, which can be used to assess heart sounds but not specifically for pulse irregularities. Choice D, percussion, is a technique used to assess the density of body tissues or detect abnormal masses and is not used to determine pulse irregularities.
A client with diabetes experiences Somogyi's effect. To prevent this complication, the nurse should instruct the client to:
- A. Take insulin at 2:00 PM each day
- B. Engage in physical activity daily
- C. Increase the dose of regular insulin
- D. Eat a protein and carbohydrate snack at bedtime
Correct Answer: D
Rationale: Somogyi effect, also known as rebound hyperglycemia, occurs as a response to nighttime hypoglycemia. Eating a protein and carbohydrate snack at bedtime can help prevent this by stabilizing blood sugar levels throughout the night. Instructing the client to take insulin at 2:00 PM each day (Choice A) may not directly address the nighttime hypoglycemia concern. Engaging in physical activity daily (Choice B) is generally beneficial for diabetes management but may not specifically prevent Somogyi's effect. Increasing the dose of regular insulin (Choice C) without addressing the nighttime hypoglycemia issue can exacerbate the problem.
The doctor has ordered 20 cc per hour of normal saline intravenously for your pediatric patient. You will be using pediatric intravenous tubing that delivers 60 cc per drop. How many drops per minute will you administer using this pediatric intravenous set?
- A. 30 drops per minute
- B. 25 drops per minute
- C. 20 drops per minute
- D. 22 drops per minute
Correct Answer: C
Rationale: To calculate the drops per minute, first convert the ordered amount to drops per minute. 20 cc per hour equals 20 drops per hour with 60 cc per drop tubing, which is equivalent to 20 drops per hour * 60 cc per drop = 1200 drops per hour. To find drops per minute, divide 1200 by 60 (minutes in an hour), which equals 20 drops per minute. Therefore, the correct answer is 20 drops per minute. Choices A, B, and D are incorrect as they do not reflect the correct calculation based on the provided information.
A client has a new diagnosis of chlamydia. Which of the following actions should the nurse take?
- A. Report the infection to the local health department
- B. Apply an antiviral cream to lesions
- C. Instruct the client to use condoms until the treatment is completed
- D. Initiate contact precautions
Correct Answer: A
Rationale: The correct answer is to report the infection to the local health department. Chlamydia is a reportable disease, meaning healthcare providers are required to report cases to public health authorities for tracking and control measures. Choice B is incorrect because chlamydia is a bacterial infection, not a viral infection, so antiviral cream would not be effective. Choice C is important advice for preventing the spread of chlamydia but is not the priority in this scenario. Choice D is not necessary for chlamydia, as it is primarily transmitted through sexual contact.