Nokea
Following the change of shift report, the nurse should analyze the information and set priorities accordingly. When the plan has been formulated, at what point during the shift can or should the nurse's plan be altered or modified?
- A. halfway through the shift
- B. at the end of the shift before the nurse reports off
- C. when needs change
- D. after the top-priority tasks have been completed
Correct Answer: C
Rationale: The nurse should modify the care plan whenever the client's needs change to ensure responsive and effective care, rather than at fixed times or only after completing tasks.
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The nurse is caring for the 11-month-old infant with bronchopulmonary dysplasia. The infant has 30% supplemental oxygen provided via a tracheostomy. Which action should the nurse take when the infant has a decline in oxygen saturation from 96% to 87% and appears anxious and restless?
- A. Obtain arterial blood gases (ABGs)
- B. Increase oxygen rate from 30% to 50%
- C. Suction the tracheostomy tube
- D. Medicate for anxiety and pain
Correct Answer: C
Rationale: C: Suctioning clears potential airway obstructions causing desaturation. A: ABGs are secondary if suctioning resolves distress. B: Increasing oxygen is ineffective with an occluded airway. D: Medication doesn't address airway issues.
Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually means the prognosis is less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be stopped.
Correct Answer: C
Rationale: The goal of palliative care is to make the client as comfortable as possible and not require a hospital stay. Prognoses vary and curative treatments can still be pursued during palliative care.
Which of the following statements is true about syphilis?
- A. The cause and mode of transmission is unclear
- B. There is no known cure for the disease
- C. When the primary lesion heals, the disease is cured
- D. Syphilis can be cured with a course of antibiotic therapy
Correct Answer: D
Rationale: Syphilis is an acute and chronic treponemal disease that can be cured with antibiotics, such as a single IM dose of long-acting penicillin G (benzathine penicillin) for primary, secondary, or early latent syphilis. The cause and transmission (sexual contact) are clear, and healing of the primary lesion does not indicate a cure without treatment.
Which of the following statements from a client may indicate that they are at a higher risk for a fall?
- A. I would like to get out of bed but would like to put on my non-skid socks first.
- B. Can you make sure the two bedrails are raised before leaving the room?
- C. I think I'm ready to walk a longer distance with the cane today.
- D. I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.
Correct Answer: D
Rationale: A client who is visually impaired without their assistive devices could be at a higher risk for a fall when ambulating.
Major competencies for the nurse giving end-of-life care include:
- A. demonstrating respect and compassion, and applying knowledge and skills in care of the family and the client.
- B. assessing and intervening to support total management of the family and client.
- C. setting goals, expectations, and dynamic changes to care for the client.
- D. keeping all sad news away from the family and client.
Correct Answer: A
Rationale: There are many competencies that the nurse must have to care for families and clients at the end of life. Demonstration of respect and compassion as well as using knowledge and skills in the care of the client and family are major competencies.