Nokea
"A patient with end-stage renal disease has a potassium level of 5 mEq/L. Based on this laboratory result, the nurse interprets which symptom as significant prompting which action?
- A. Drowsiness, stimulate the patient every 30 minutes
- B. Confusion, ask the patient to state their name and date of birth
- C. Irregular heartbeat, evaluate the patient's capillary refill
- D. Muscle cramps, elevate the affected limb"
Correct Answer: C
Rationale: Rationale for Correct Answer C: Irregular heartbeat is a significant symptom of hyperkalemia, which can be life-threatening. The nurse should evaluate capillary refill to assess perfusion. High potassium levels can affect cardiac function, leading to arrhythmias. Monitoring capillary refill provides insight into tissue perfusion, helping to assess the severity of the condition and guide appropriate interventions.
Summary of Incorrect Choices:
A: Drowsiness is not a typical symptom of hyperkalemia. Stimulating the patient every 30 minutes does not address the underlying issue.
B: Confusion is not a common symptom of hyperkalemia. Asking the patient to state their name and birthdate does not address the cardiac implications of high potassium levels.
D: Muscle cramps may occur with hyperkalemia but are not as critical as irregular heartbeat. Elevating the affected limb is not the priority in this situation.
You may also like to solve these questions
When the client is unable to make medical decisions for himself or herself, authorization that allows another person to make these decisions is called:
- A. living will.
- B. durable power of attorney.
- C. informed consent.
- D. immunity.
Correct Answer: B
Rationale: The correct answer is B: durable power of attorney. This legal document grants authority to another person, known as the healthcare proxy or agent, to make medical decisions on behalf of the client when they are unable to do so themselves. This is essential for ensuring that the client's wishes are respected and that appropriate medical care is provided.
A: A living will is a document that outlines a person's preferences for medical treatment in case they become incapacitated, but it does not appoint someone to make decisions on their behalf.
C: Informed consent is the process of ensuring that a patient understands the risks and benefits of a medical treatment before giving consent, but it does not authorize someone to make decisions on their behalf.
D: Immunity refers to protection from legal liability and is not relevant to authorizing someone to make medical decisions for a client.
On the National Council Licensure Examination for Registered Nurses (NCLEX-RN) examination, when the candidate is asked to set goals in collaboration with other members of the health care team, the nurse is being tested in the area of:
- A. assessment.
- B. planning.
- C. analysis.
- D. implementation.
Correct Answer: B
Rationale: The correct answer is B: planning. Setting goals in collaboration with other healthcare team members falls under the planning phase of the nursing process. During this phase, nurses work with the healthcare team to establish specific, measurable, achievable, relevant, and time-bound (SMART) goals for patient care. This involves identifying priorities, outlining interventions, and determining the expected outcomes. Collaboration with the healthcare team ensures that goals are comprehensive and align with the overall care plan.
Incorrect Choices:
A: Assessment - Assessment involves collecting and analyzing data to identify the patient's needs and problems. Setting goals is not part of the assessment phase.
C: Analysis - Analysis involves interpreting data and identifying patterns or relationships. Setting goals is more focused on planning and identifying interventions.
D: Implementation - Implementation involves carrying out the planned interventions to achieve the established goals. Setting goals precedes the implementation phase.
A nurse hopes to improve time management skills using the ABC prioritization approach. Which tasks would be prioritized as "B"? (select all that apply)
- A. Turn in time sheet due in 3 days.
- B. Review dress code policy to give feedback before appointment in the morning.
- C. Perform blood glucose test on a patient admitted with Kussmaul respirations and change in level of consciousness.
- D. Complete patient teaching prior to discharge in 2 hours.
Correct Answer: B
Rationale: The correct answer is B because reviewing the dress code policy to give feedback before an appointment in the morning is time-sensitive and directly impacts the nurse's professional responsibilities. This task falls under the "B" category in the ABC prioritization approach, which prioritizes tasks that are important but not urgent. This task requires attention before the morning appointment to ensure professionalism and compliance.
Tasks A, C, and D are not prioritized as "B" because they are either more urgent or less important compared to reviewing the dress code policy before the morning appointment. Task A is important but not urgent as the time sheet is not due immediately. Task C is categorized as "A" as it involves a critical patient situation that requires immediate attention. Task D is categorized as "C" as it is important and time-sensitive, needing completion before discharge in 2 hours.
A patient is admitted with hypotension, shortness of breath, flushing, and hives. All levels of staff have been trained to assess vital signs. Given budget restrictions and proper delegation rules, to which care provider would the RN delegate the task of obtaining the initial blood pressure reading?
- A. RN
- B. LPN/LVN
- C. Unlicensed assistive personnel (UAP)
- D. Use the blood pressure obtained in the ambulance, because it was assessed via electronic monitoring.
Correct Answer: C
Rationale: The correct answer is C. The Unlicensed Assistive Personnel (UAP) can be delegated the task of obtaining the initial blood pressure reading because this task is within their scope of practice and does not require specialized nursing knowledge or assessment skills. The UAP can be trained and supervised to accurately measure blood pressure, freeing up the RN to focus on assessing the patient's overall condition and providing necessary interventions. Delegating this task to the UAP is cost-effective and efficient, allowing the RN to prioritize critical nursing assessments and interventions for the patient's presenting symptoms.
Incorrect choices:
A: RN - The RN should not perform tasks that can be safely delegated to other members of the healthcare team to optimize efficiency and resource utilization.
B: LPN/LVN - While LPNs/LVNs have more advanced training than UAPs, obtaining a blood pressure reading is a basic task that can be appropriately delegated to UAPs.
D: Using the blood pressure obtained in the ambulance - This option does
A director of nursing (DON) asks the staff to list how their nursing unit can help the organization meet its goal to "provide quality patient care with attention to compassion and excellence." An ad hoc committee is formed to develop a timeline of identified actions. The DON coaches the committee to reach desired outcomes. This DON is demonstrating which other role of leadership and management?
- A. Transactional
- B. Clinical consultant
- C. Corporate supporter
- D. Autocratic
Correct Answer: B
Rationale: The correct answer is B: Clinical consultant. In this scenario, the DON is providing guidance and expertise to the ad hoc committee in developing strategies to meet the organization's goal of providing quality patient care. As a clinical consultant, the DON utilizes their clinical knowledge and experience to coach and support the committee in achieving desired outcomes related to patient care. The other choices are incorrect because:
A: Transactional leadership focuses on exchanging rewards for performance and does not align with the DON's role in providing clinical guidance.
C: Corporate supporter role involves advocating for organizational goals at a higher level and is not directly related to coaching a committee on clinical matters.
D: Autocratic leadership style is characterized by making decisions without input from others, which is not demonstrated in the scenario where the DON is coaching and guiding the committee.