Nokea
By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process?
- A. Reassess client to determine reasons for unsatisfactory pain relief
- B. See whether pain lessens during next 24h
- C. Change plan to ensure client achieves adequate pain relief
- D. Teach client about plan of care for managing his pain
Correct Answer: A
Rationale: The correct answer is A. In the nursing process, the first step in addressing a client's unsatisfactory pain relief is to reassess the client to determine the reasons for it. This involves evaluating the pain intensity, location, characteristics, aggravating factors, and the client's response to current pain management interventions. By reassessing, the nurse can identify any underlying causes contributing to the lack of pain relief and adjust the plan of care accordingly.
Choice B is incorrect because waiting another 24 hours without further assessment delays appropriate intervention. Choice C is incorrect as changing the plan without reassessment may not address the root cause of the issue. Choice D is incorrect as teaching the client about the plan of care should come after reassessment to ensure it is tailored to the client's specific needs.
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Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information such as location, type of environment, and potential threats. By gathering this information discreetly, security personnel can better assess the situation and coordinate an appropriate response.
Choice A is incorrect because abruptly ending the call can hinder the ability to gather vital details. Choice B is incorrect as using overhead paging may cause panic and compromise safety. Choice C is incorrect because not asking questions can lead to missing important information.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face, neck, chest
- D. Client with fractured fibula & tibia
Correct Answer: C
Rationale: The correct answer is C because clients with partial & full-thickness burns to face, neck, chest are the highest priority during a mass casualty event. This is due to the potential for airway compromise and risk of respiratory distress. Burns to these areas can cause swelling and compromise the airway, leading to respiratory distress and possible respiratory failure. Immediate intervention is crucial to ensure adequate oxygenation and ventilation. Clients with crush injuries (A) or fractures (D) may have serious injuries but are not at immediate risk of airway compromise. A laceration to the head (B) may require urgent attention but is not as life-threatening as airway compromise.
Nurse observes smoke coming from under door of staff lounge. Which is priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The priority action for the nurse in this scenario is to evacuate the clients (Choice C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (Choice B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (Choice A) may put the nurse at risk and delay client evacuation. Closing doors (Choice D) may contain the fire but does not address the immediate need of client safety.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. At age 2, children often exhibit behaviors to assert their independence. By saying 'no' and resisting help with dressing, the toddler is showing a desire to do things on her own and asserting her autonomy. This behavior aligns with the typical developmental stage of toddlers seeking independence and autonomy. Choices B, C, and D are incorrect because they do not align with the typical behaviors and developmental milestones of a 2-year-old. Choice B (Developing sense of trust) is more characteristic of infancy, choice C (Manifesting anger management problem) is not appropriate for a toddler's behavior in this context, and choice D (Attempting to finish a project she started) does not reflect the developmental stage of a 2-year-old.
Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.