Nokea
During the evaluation phase for a client, the nurse should focus on
- A. All finding of physical and psychosocial stressors of the client and in the family
- B. The client's status, progress toward goal achievement, and ongoing re-evaluation
- C. Setting short and long-term goals to insure continuity of care from hospital to home
- D. Select interventions that are measurable and achievable within selected timeframes
Correct Answer: B
Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.
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At a nursing staff meeting, there is discussion of perceived inequities in weekend staff assignments. As a follow-up, the nurse manager should initially
- A. Allow the staff to change assignments
- B. Identify reasons for current assignments
- C. Help staff see the complexity of issues
- D. Facilitate creative thinking on staffing
Correct Answer: D
Rationale: Facilitate creative thinking on staffing. The 'moving phase' of change involves viewing the problem from a new perspective, and then incorporating new and different approaches to the problem. The manager, as a change agent, can facilitate staff's solving the problem.
Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
A category 4 hurricane has affected a rural, local health care system, creating a significant increase in emergency department admissions. Which of the following clients should the nurse anticipate as the priority for intervention?
- A. Client with status asthmaticus and a pulse oximetry reading of 89%
- B. Client with diabetes mellitus reporting a headache after being involved in a minor motor vehicle collision
- C. Client who is 11 weeks pregnant, has gestational diabetes, and nausea and vomiting over the past 2 days
- D. Client with diabites mellitus with a serum glucose level of 690 mg/dl (38.3 mmol/L ,abdominal pain, and fatigue)
Correct Answer: A
Rationale: Status asthmaticus with 80% pulse oximetry (A) indicates severe hypoxia, requiring immediate intervention to prevent respiratory failure. Headache post-collision (B) and nausea in pregnancy (C) are less acute, as they do not indicate immediate life-threatening conditions.
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish her supply every three months.
- B. Take one every 15 minutes if pain occurs.
- C. Leave the medication in the brown bottle.
- D. Crush the medication and take it with water.
Correct Answer: C
Rationale: The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.
A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?
- A. Encourage the visitor to lie down to see if symptoms change
- B. Initiate protocol to assist the visitor to the emergency department
- C. Proceed to take the visitor's blood pressure
- D. Suggest that the visitor call the health care provider
Correct Answer: B
Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (B) ensures timely care. Lying down (A), taking blood pressure (C), or calling a provider (D) delays critical intervention.
A client on hospice home care is taking sips of water but refusing food. Family members appear distressed and insist that the personal care worker 'force feed' the client. What is the priority nursing action?
- A. Explain to the family that this is a normal physiological response to dying
- B. Explore the family’s thoughts and concerns about the client’s refusal of food
- C. Recommend a feeding tube
- D. Tell the family that 'force feeding' the client could cause the client to choke on the food
Correct Answer: A
Rationale: Explaining that anorexia is normal in dying (A) addresses family distress and aligns with hospice goals. Exploring concerns (B) is secondary, feeding tubes (C) are inappropriate, and choking warnings (D) may escalate distress.