Nokea
Before administering an intramuscular injection, the nurse's finger is stuck with the needle. Which action should the nurse take?
- A. Go to the emergency room to have blood drawn
- B. Prepare the medication using a new syringe
- C. Apply clean gloves before giving the medication
- D. Review the medical history in the client's chart
Correct Answer: B
Rationale: In this scenario, if the nurse's finger is stuck with the needle before administering the injection, the correct action is to prepare the medication using a new syringe. This step is crucial to prevent contamination and ensure the safety of the patient. Going to the emergency room to have blood drawn is unnecessary and does not address the immediate issue of contamination. Applying clean gloves is important for infection control but does not address the potential contamination from the needlestick. Reviewing the medical history in the client's chart is important for overall patient care but is not the priority in this situation where immediate action is required to prevent harm.
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A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out." The nurse recognizes that the client is using which defense mechanism?
- A. Denial
- B. Splitting
- C. Projection
- D. Rationalization
Correct Answer: C
Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.
In preparing a care plan for a client admitted with a diagnosis of Guillain-Barre syndrome, which nursing problem has the highest priority?
- A. Ineffective coping related to uncertainty of disease progression
- B. Imbalanced nutrition: less than body requirements related to impaired swallowing reflex
- C. Ineffective breathing pattern related to ascending paralysis
- D. Impaired physical mobility related to asymmetrical descending paralysis
Correct Answer: C
Rationale: Ineffective breathing pattern is the highest priority nursing problem for a client with Guillain-Barre syndrome due to the potential risk of respiratory failure. As the paralysis ascends, it can affect the muscles needed for breathing, leading to respiratory compromise. Addressing this problem promptly is crucial to prevent respiratory distress and failure. Choices A, B, and D are also important nursing problems in Guillain-Barre syndrome, but ensuring effective breathing takes precedence over coping, nutrition, and mobility due to the immediate threat it poses to the client's life.
A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?
- A. Anxiety related to treatment plan
- B. Deficient knowledge of lifestyle changes
- C. Ineffective coping related to denial
- D. Decisional conflict due to stress
Correct Answer: C
Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.
The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
- A. Evaluate the client for sleep disturbances
- B. limit client exercise
- C. Report any client complaint of pain or discomfort
- D. Note and report the client's food and liquid intake during meals and snacks
Correct Answer: D
Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.
A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor urine output hourly
- B. Assess for back muscle aches
- C. Record drainage from the drain
- D. Obtain body weight daily
Correct Answer: C
Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.