Alcohol, caffeine, or drugs are high-risk factors that all fall under which broad classification of risk factors?
- A. Social demographic
- B. Environmental
- C. Biophysical
- D. Psychosocial
Correct Answer: D
Rationale: The correct answer is D: Psychosocial. Alcohol, caffeine, or drug use are considered psychosocial risk factors as they are related to individual behavior, lifestyle choices, and social interactions. Choices A, B, and C are incorrect. Social demographic factors (choice A) refer to characteristics of a population such as age, gender, education, income, etc. Environmental factors (choice B) include physical surroundings like air quality, housing conditions, etc. Biophysical factors (choice C) involve biological aspects like genetics, physiology, and health conditions.
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Dr. Shrunk orders intravenous (IV) insulin for Rita, a client with a blood sugar of 563. Nurse AJ administers insulin lispro (Humalog) intravenously (IV). What does the best evaluation of the nurse reveal? Select one that does not apply.
- A. The nurse could have given the insulin subcutaneously.
- B. The nurse did not have to contact the physician.
- C. The nurse should have used regular insulin (Humulin R).
- D. The nurse used the correct insulin.
Correct Answer: C
Rationale: The best evaluation of the nurse reveals that she should have used regular insulin (Humulin R) for IV administration. Regular insulin is the only insulin approved for intravenous administration due to its pharmacokinetic properties. Insulin lispro (Humalog) is not suitable for IV use. Choice A is incorrect because giving insulin intravenously is necessary in this case of high blood sugar. Choice B is incorrect because administering a different insulin without consulting the physician is not appropriate. Choice D is incorrect because the nurse used the incorrect insulin, which could pose risks to the client's health.
A nurse is preparing a client for surgery. The client has signed the consent form but tells the nurse that she has reconsidered because she is worried about the pain. Which of the following responses by the nurse is appropriate?
- A. If you have the procedure now, you won't have to deal with pain and disability later.
- B. You'll be fine. You'll receive a prescription for pain medication.
- C. Why didn't you discuss your concerns with your provider?
- D. I understand and it's not too late to change your mind.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?
- A. I hope I can adjust to using crutches while I am recovering.
- B. I am worried about taking care of my toddler at home.
- C. I just don't think I can handle looking at my leg.
- D. I am not sure how I will pay for all the therapy I will need.
Correct Answer: A
Rationale: The client's statement about adjusting to using crutches while recovering suggests a potential need for occupational therapy referral. Occupational therapists assist individuals in regaining independence in activities of daily living, including mobility aids and adaptations. Choices B, C, and D are more indicative of emotional or financial concerns and may require referrals to other healthcare professionals like counselors or financial advisors, rather than occupational therapists.
The wound irrigation process cleanses the wound and:
- A. Reduces the potential pain in the wound region or area.
- B. Stops the spread of infection by creating a 'clean' area.
- C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
- D. Allows for the introduction of medications in solution form.
Correct Answer: D
Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.
A nurse is assisting with the orientation of a newly licensed nurse. The newly licensed nurse is having trouble focusing and has difficulty completing care for his assigned clients. Which of the following interventions is appropriate?
- A. Offer to provide care for his clients while he takes a break
- B. Advise him to complete less time-consuming tasks first
- C. Ask other staff members to take over some of his tasks
- D. Recommend that he take time to plan at the beginning of his shift
Correct Answer: D
Rationale: The correct intervention is to recommend that the new nurse takes time to plan at the beginning of his shift. Planning ahead can help improve time management and focus. Option A is not ideal as it does not address the root cause of the issue and may not promote independence. Option B may not be effective if the nurse is struggling with time management in general. Option C involves shifting responsibilities to others without addressing the new nurse's need for improvement in managing his workload, which should be the priority.