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In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms.
- B. nutritional status.
- C. bleeding problems.
- D. availability of insulin.
Correct Answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.
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When a client needs oxygen therapy, what is the highest flow rate that oxygen can be delivered via nasal cannula?
- A. 2 liters/minute
- B. 4 liters/minute
- C. 6 liters/minute
- D. 8 liters/minute
Correct Answer: C
Rationale: The correct answer is 6 liters/minute. When a client requires oxygen therapy, the maximum flow rate that oxygen can be delivered via nasal cannula is 6 liters/minute. Nasal cannula can effectively deliver oxygen up to 6 liters/minute. Flow rates exceeding 6 liters/minute may lead to drying of the nasal passages and discomfort for the client. Higher flow rates, like 8 liters/minute, should be administered using a mask to ensure sufficient oxygenation. Options A, B, and D are incorrect as they indicate flow rates that surpass the recommended maximum for nasal cannula delivery.
A nurse discusses staff empowerment with the nursing team. The nurse explains that staff empowerment has which function?
- A. Fosters the growth of others so that they are less dependent on the leader
- B. Means that the staff has the power to reprimand and punish any individual who is not meeting the standards of care delivery
- C. Indicates that the nurse leader will make decisions regarding the nursing unit and expects that the staff will comply with the changes
- D. Allows the staff to make every decision regarding employee scheduling
Correct Answer: A
Rationale: Staff empowerment fosters the growth of others and facilitates their development so that they are less dependent on their leader. This empowerment is about enhancing skills and autonomy, not about reprimanding or punishing others (Choice B). Empowerment involves shared decision-making and autonomy, not unilateral decision-making by the leader (Choice C). Moreover, staff empowerment does not mean that staff should make every decision regarding operational aspects like employee scheduling (Choice D). It is primarily focused on developing individuals' capabilities and fostering independence within the team.
All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:
- A. Increase maternal fluids.
- B. Administer oxygen.
- C. Decrease maternal fluids.
- D. Turn the mother.
Correct Answer: C
Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.
An LPN is talking with a client scheduled to undergo a vasectomy in the next few minutes. He states, "I know I signed the form and all, but I'm not feeling so sure of this. It can be reversed pretty easily, right?"? What is the LPN's best response?
- A. "Yes, vasectomies can be reversed, but once you have it, you may regret it later."?
- B. "It's normal to feel a little nervous before a procedure like this."?
- C. "It sounds like you have a few more questions you'd like answered. Let me grab the doctor quickly so he can answer them for you."?
- D. "It sounds like you might be a little nervous. Don't worry, this is a pretty minor procedure, and the doctor doing it is the best we have. You're in great hands."?
Correct Answer: C
Rationale: The best response for the LPN is to acknowledge the client's concerns and offer to provide more information. By offering to get the doctor to answer any additional questions, the LPN shows respect for the client's right to informed consent. Option A provides some information but dismisses the client's uncertainty and implies they won't regret the decision, which may not be the case. Option B acknowledges nervousness but doesn't directly address the client's request for more information. Option D attempts to reassure the client but fails to address the need for additional questions to be answered by the doctor.
A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?
- A. Check the unit policy for the protocol for the care of clients who have been sexually assaulted.
- B. Ask a medical assistant.
- C. Call the nurse in charge of the day shift.
- D. Ask the police officers who brought the client to the center.
Correct Answer: A
Rationale: Accountability in nursing involves taking responsibility for one's actions and decisions. In this scenario, checking the unit policy for the protocol related to the care of sexually assaulted clients demonstrates accountability. Policies and protocols provide guidance on appropriate actions and responsibilities in specific situations. Asking a medical assistant, calling the day shift nurse in charge, or consulting police officers are not appropriate actions to demonstrate accountability in this context. Seeking further clarification from the agency nursing supervisor on the night shift after reviewing the policy or protocol would be a more suitable course of action.