Nokea
A nursing assistant asks why the client with a chronically low phosphorus level needs so much assistance with activities of daily living. What is your best response?
- A. “The client's low phosphorus is probably due to malnutrition.”
- B. “The client is just worn out from not getting enough rest.”
- C. “The client's skeletal muscles are weak because of the low phosphorus.”
- D. “The client will do more for herself when her phosphorus is normal.”
Correct Answer: C
Rationale: Low phosphorus levels impair energy production in cells, leading to muscle weakness and fatigue, which explains the need for assistance.
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A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
- A. Determining if the UAP knew how to take blood pressure
- B. Double-checking the UAP by taking another blood pressure
- C. Providing more appropriate supervision of the UAP
- D. Taking the blood pressure instead of delegating the task
Correct Answer: C
Rationale: The correct answer is C: Providing more appropriate supervision of the UAP. By providing adequate supervision, the nurse can ensure that the UAP is performing tasks correctly and can intervene if any issues arise. This would have likely prevented the negative outcome as the nurse could have identified the high blood pressure and changed mental status earlier.
A: Determining if the UAP knew how to take blood pressure - While assessing the UAP's competence is important, it does not address the need for ongoing supervision and oversight.
B: Double-checking the UAP by taking another blood pressure - This approach does not address the root cause of the issue, which is the lack of appropriate supervision.
D: Taking the blood pressure instead of delegating the task - This is not a sustainable solution as delegating tasks to UAPs is a common practice in healthcare settings. Providing appropriate supervision is key to ensuring safe and effective delegation.
A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding should you instruct the student to report immediately?
- A. Respiratory rate of 8 to 10 per minute
- B. Pain level decreased from 6/10 to 2/10
- C. Client requests room door be closed
- D. Heart rate 90-100 per minute
Correct Answer: A
Rationale: Oxycodone can depress respiration; a respiratory rate of 8-10 per minute is abnormally low and requires immediate attention to prevent respiratory failure.
A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.
Match the following care planning tools to the description statement(s). There may be more than one statement per tool and some statements may be used more than once.
- A. Nursing Care Plan
- B. Concept Maps
- C. Clinical Pathway
- D. All
Correct Answer: A
Rationale: Nursing Care Plans direct teams, Concept Maps visualize relationships, and Clinical Pathways guide predictable cases.
During a call to the on-call physician about a client who had a hysterectomy 2 days ago & has unrelieved pain from prescribed narcotic medication, which statement is part of the SBAR format for communication?
- A. I suggest ordering a different pain medication.
- B. This client has allergies to morphine & codeine.
- C. Dr. Smith does not prefer nonsteroidal anti-inflammatory meds.
- D. The client had a vaginal hysterectomy 2 days ago.
Correct Answer: B
Rationale: The correct answer is B because it provides relevant information regarding the client's allergies to morphine and codeine, which is crucial for the physician to know when considering alternative pain medication options. This aligns with the "Background" component of the SBAR format, which includes pertinent patient history.
Choice A is incorrect because it jumps to a solution without providing necessary background information. Choice C is irrelevant to the current situation as it does not address the client's pain management issue. Choice D is also incorrect as it only provides historical information about the type of hysterectomy performed, which is not directly related to the client's current pain management concern.