All of the following are common reasons that nurses are reluctant to delegate except:
- A. lack of self-confidence.
- B. desire to maintain authority.
- C. confidence in subordinates.
- D. getting trapped in the 'I can do it better myself' mindset.
Correct Answer: C
Rationale: If a delegator has confidence in his subordinates and feels that a task will be performed correctly, he is more likely to delegate. Reasons that delegators are reluctant to delegate include their own lack of confidence, fear of losing authority or personal satisfaction, and feeling that the task can only be performed correctly if they do it themselves.
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A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO0. How many milliliters of fluid did the patient ingest?
- A. $440 \mathrm{ml}$
- B. $480 \mathrm{ml}$
- C. $22 \mathrm{ml}$
- D. $660 \mathrm{ml$
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.
Before ambulating the client for the first time, the nurse obtains the client's BP with an automatic BP machine. Which actions should the nurse take first when obtaining a BP reading of 86/56 mm Hg and pulse rate of 64 bpm?
- A. Assess the client for dizziness and feel the temperature of extremities
- B. Obtain a manual BP cuff and machine and retake the client's BP
- C. Elevate the head of the client's bed and assist the client out of bed
- D. Review the medical record and determine the client's normal BP range
Correct Answer: A
Rationale: A: Assessing for hypotension symptoms like dizziness or cold extremities is priority. B: Retaking BP follows assessment. C: Ambulating risks falls with hypotension. D: Reviewing records is secondary.
The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible.
- B. taking care of the whole person-body, mind, spirit, heart, and soul.
- C. no interventions are needed because the client is near death.
- D. support of needs of the family and client.
Correct Answer: C
Rationale: The goals of palliative care include choices A, B, and D. Choice C is not part of palliative care. All aspects of medical, emotional, social, and spiritual needs of the dying client should be focused on until the end of life.
Assessment of a client with a cast should include:
- A. capillary refill, warm toes, no discomfort.
- B. posterior tibial pulses, warm toes.
- C. moist skin essential, pain threshold.
- D. discomfort of the metacarpals.
Correct Answer: A
Rationale: Assessment for adequate circulation is necessary. Signs of impaired circulation include slow capillary refill, cool fingers or toes, and pain.
A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?
- A. shopping for groceries
- B. house cleaning
- C. transportation to physician's visits
- D. medication instruction
Correct Answer: D
Rationale: The only skilled service listed is medication instruction. Grocery shopping, house-cleaning services, and transportation services are all examples of unskilled services offered by volunteer and fee-for-service agencies.