Nokea
Nurse tells client that she will call surgeon & ask about his request. Surgeon hears nurse's report & prescribes full liquid diet. Nurse used which of following levels of critical thinking?
- A. basic
- B. commitment
- C. complex
- D. integrity
Correct Answer: A
Rationale: The correct answer is A: basic. In this scenario, the nurse is simply relaying information and following a routine procedure by contacting the surgeon for a prescription. This level of critical thinking involves basic understanding and application of knowledge without deeper analysis or evaluation. The other choices are incorrect because: B: commitment involves making decisions and taking responsibility; C: complex involves analyzing and evaluating information; D: integrity involves ethical decision-making. In this case, the nurse's action aligns with basic thinking as she is following a standard protocol without engaging in higher-level critical thinking processes.
You may also like to solve these questions
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 caring for client just admitted after falling. This client is oriented 3x & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply.)
- A. Place belt restraint on him when he's sitting on bedside commode
- B. Keep bed in low position with full side rails up
- C. Ensure client's call light is within reach
- D. Provide client with nonskid footwear
- E. Complete fall-risk assessment
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Ensuring the client's call light is within reach allows them to easily call for assistance, reducing the risk of falls.
D: Providing the client with nonskid footwear enhances traction, decreasing the likelihood of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's fall risk, enabling tailored interventions for prevention.
Incorrect Choices:
A: Placing a belt restraint on the client when sitting on the commode can lead to loss of autonomy and increase agitation, potentially escalating fall risk.
B: Keeping the bed in a low position with full side rails up may restrict the client's movement and independence, leading to frustration and potential attempts to climb out, increasing the risk of falls.
Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.)
- A. Family members who smoke must be at least 10 ft from client when his oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.
Incorrect Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,
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.
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.