Nokea
A patient has come to the office for a blood draw. The patient starts to sweat and is very anxious. Which of the following would be the BEST way to proceed?
- A. Do not perform the procedure. Notify the physician of the reason why.
- B. Perform the procedure but pay close attention for signs of potential syncope.
- C. Allow the patient to reschedule for a time when he isn't as anxious.
- D. Have the physician draw the blood.
Correct Answer: B
Rationale: In the scenario where a patient is sweating and anxious, it is important to assess for signs of potential syncope (fainting) while proceeding with the blood draw. If the patient does not exhibit signs of fainting, the phlebotomy procedure can be performed safely. Postponing the procedure may not address the patient's anxiety and inconvenience them. Having the physician draw the blood is not necessary if the phlebotomist can handle the situation effectively.
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The client starting an exercise program will progress to walking a 20-minute mile in one month.
- A. Client will walk quickly three times a day
- B. Client will be able to walk a mile
- C. Client will have no alteration in breathing during the walk
- D. Client will progress to walking a 20-minute mile in one month
Correct Answer: D
Rationale: Outcome statements must be written in behavioral terms and identify specific, measurable client behaviors. They are stated in terms of the client with an action verb that, under identified conditions, will achieve the desired behavior. Choice A lacks specificity and does not mention a target time or goal. Choice B is vague and does not provide a specific target for improvement. Choice C focuses on a negative outcome (no alteration) rather than a positive goal. The correct answer, Choice D, is specific, measurable, and time-bound, making it a suitable outcome statement for a client starting an exercise program.
The client is being discharged to a long-term care (LTC) facility. The nurse is preparing a progress note to communicate to the LTC staff the client's outcome goals that were met and those that were not. To do this effectively, the nurse should:
- A. Formulate post-discharge nursing diagnoses
- B. Draw conclusion about resolution of current client problems
- C. Assess the client for baseline data to be used at the LTC facility
- D. Plan the care that is needed in the LTC facility
Correct Answer: B
Rationale: To effectively communicate the client's outcome goals that were met and those that were not to the LTC staff, the nurse should draw conclusions about the resolution of the current client problems. Terminal evaluation is performed to determine the client's condition at discharge, focusing on which goals were achieved and which were not. Formulating post-discharge nursing diagnoses (option A) is not the most appropriate action in this scenario as it focuses on identifying potential problems after discharge rather than evaluating achieved goals. Assessing the client for baseline data (option C) is not necessary at this point as the focus is on evaluating outcomes rather than collecting baseline data. Planning the care needed in the LTC facility (option D) is premature as this should be done on admission to the LTC facility and not during the discharge process.
The rehabilitation nurse wishes to make the following entry into a client's plan of care: 'Client will reestablish a pattern of daily bowel movements without straining within two months.' The nurse would write this statement under which section of the plan of care?
- A. Nursing diagnosis/problem list
- B. Nursing orders
- C. Short-term goals
- D. Long-term goals
Correct Answer: D
Rationale: The correct answer is 'Long-term goals.' Long-term goals are designed to describe changes in client behavior expected over a time frame greater than one week. In this case, the goal of reestablishing a pattern of daily bowel movements without straining within two months falls under a long-term goal. Long-term goals are aimed at restoring normal functioning in a problem area and are beneficial for healthcare workers caring for the client across different settings. Choices A, B, and C are incorrect because nursing diagnosis/problem list, nursing orders, and short-term goals do not encompass the desired timeframe or level of expected change in this scenario.
Which vacutainer tubes should be used when a requisition calls for blood to be drawn for an H&H and glucose test?
- A. One light blue, one red
- B. Two lavenders
- C. One lavender, one grey
- D. One green, one red
Correct Answer: D
Rationale: The correct answer is 'One green, one red.' An H&H test involves hemoglobin and hematocrit, which are components of a complete blood count and are typically drawn in a lavender tube. On the other hand, blood for glucose testing is collected in grey tubes. Therefore, when drawing blood for both an H&H and glucose test, one green tube for glucose and one red tube for H&H should be used. The other choices are incorrect because light blue tubes are used for coagulation studies, lavender tubes are for complete blood counts, and green tubes are for chemistry tests like glucose, while grey tubes are specifically for glucose testing.
During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?
- A. Ask the patient how he or she is feeling.
- B. Document the findings in the patient's record.
- C. Wait 10 minutes and auscultate the sound again.
- D. Ask another nurse to double-check the finding.
Correct Answer: D
Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.