Nokea
Let me know how you're doing and whether you need any help."
- A. "Give the patient in 204A a shower after breakfast, and call me to check her feet before you get her dressed."
- B. "Take the vital signs on all the patients in the lounge and tell me whether there are problems." The clarity and brevity of the direction makes the delegated task clear and leaves the responsibility of assessment to the nurse.
Correct Answer: B
Rationale: The correct answer is B because it provides clear instructions to take vital signs on all patients in the lounge and report any problems. This ensures comprehensive assessment and communication. Choice A is incorrect because it lacks specificity and may lead to overlooking important tasks. Choice C and D are incorrect as they are blank. Providing clear and concise directions is crucial in delegation to ensure tasks are completed accurately and efficiently.
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The first-semester nursing student tells the team leader that her clinical assignment for the day is to take vital signs and obtain a client history that will take about 1 or 2 hours to complete. Which clients would the leader recommend that she approach to fulfill her assignment? (Select all that apply.)
- A. Mr. N (non-Hodgkin lymphoma)
- B. Mr. L (tracheostomy and partial laryngectomy)
- C. Mr. B (bladder cancer)
- D. Ms. C (bowel resection and colostomy)
Correct Answer: B
Rationale: The correct answer is B because Mr. L, who has a tracheostomy and partial laryngectomy, will likely require vital signs monitoring and a detailed client history due to his complex respiratory and communication needs. This assignment will provide the student with valuable experience in caring for clients with specialized needs.
Incorrect choices:
A: Mr. N (non-Hodgkin lymphoma) - While Mr. N may require vital signs monitoring, his condition does not necessarily involve complex care needs that would warrant a 1-2 hour history-taking session.
C: Mr. B (bladder cancer) - Vital signs monitoring and history-taking for a client with bladder cancer may not require as much time as the scenario suggests, as the care needs may not be as complex as those of a client with a tracheostomy and laryngectomy.
D: Ms. C (bowel resection and colostomy) - While Ms. C may require vital signs monitoring and history-taking
A patient who has had a stroke is unable to speak clearly and has right sided hemiplegia. The nurse will design the approach to the assessment interview by:
- A. asking questions and explaining procedures to the patient's daughter.
- B. speaking slowly and giving the patient time to respond.
- C. telling the patient he will get all necessary information from the daughter.
- D. prompting the answers and finishing the sentences for the patient. Speaking slowly recognizes that the patient may process (if able) information more slowly.
Correct Answer: B
Rationale: The correct answer is B because speaking slowly and giving the patient time to respond allows the patient with speech difficulties due to the stroke to process information and formulate a response. Prompting or finishing sentences can hinder the patient's ability to communicate independently. Asking questions to the patient directly, rather than relying on a family member, ensures accurate information is obtained directly from the patient. Telling the patient that all information will come from the daughter undermines the patient's autonomy and may lead to incomplete or inaccurate information.
The nurse makes a home visit to a client with chronic kidney disease. The client asks the nurse to make the decision about whether or not to start dialysis. Which action by the nurse is most appropriate?
- A. Encourage the client to appoint a durable power of attorney.
- B. Invite the client to make a decision after reviewing options.
- C. Direct the client to have the physician make a decision.
- D. Have the client visit with an individual receiving dialysis.
Correct Answer: B
Rationale: Step 1: The nurse should respect the client's autonomy and involve them in decision-making.
Step 2: By inviting the client to make a decision after reviewing options, the nurse promotes client-centered care.
Step 3: This approach empowers the client to participate actively in their healthcare decisions.
Step 4: It aligns with ethical principles of beneficence and nonmaleficence.
Summary:
Choice B is correct as it respects the client's autonomy and promotes shared decision-making. Choice A is not appropriate as it bypasses the client's involvement. Choice C is not ideal as the client should be actively involved. Choice D may provide information but doesn't involve the client in decision-making.
According to the Workplace Bullying Institute, nurses are also exposed to this type of behavior within their professional environment. In teaching the possibility to an incoming graduate nurse, you know that the nurse understands when he or she includes which of the following as abusive conduct? (Select all that apply)
- A. Threats
- B. Humiliation
- C. Intimidation
- D. Physical abuse
Correct Answer: A
Rationale: The correct answer is A: Threats. Threats are considered abusive conduct in the context of workplace bullying. Nurses may be subjected to threats that create a hostile work environment. Threats can instill fear and distress in the victim, affecting their well-being and performance.
Summary of why other choices are incorrect:
B: Humiliation - While humiliation is a form of abuse, the question specifically asks about abusive conduct in the context of workplace bullying for nurses.
C: Intimidation - Intimidation is another form of abusive behavior, but the question focuses on identifying abusive conduct in the workplace environment for nurses.
D: Physical abuse - While physical abuse is a serious issue, the question pertains to identifying abusive conduct within the professional environment for nurses, where physical abuse may not be as common as other forms of bullying behavior.
The home health nurse visits a client with heart failure who has increased dyspnea and peripheral edema and weight gain. The nurse suspects the client is not restricting fluids as prescribed. Which action by the nurse is most appropriate?
- A. Teach the client about the consequences of not following the fluid restrictions.
- B. Ask the client to report the amount of fluid intake for the past 24 hours.
- C. Provide the client with sugarless candy or gum to decrease the thirst sensation.
- D. Consult with the healthcare provider about increasing the dose of the diuretic.
Correct Answer: B
Rationale: The most appropriate action for the nurse is to ask the client to report the amount of fluid intake for the past 24 hours. This is the correct answer because it directly addresses the issue of non-compliance with fluid restrictions. By assessing the actual fluid intake, the nurse can identify the extent of the problem and provide targeted interventions.
Option A is not the best choice as teaching about consequences may not address the immediate issue. Option C does not address the root cause of the problem but only provides a temporary solution. Option D is not appropriate as increasing the diuretic dose should be done in collaboration with the healthcare provider after assessing the client's current condition.