Nokea
The charge nurse considers both patient-related and staff-related factors when making daily assignments. All of the following are patient-related factors EXCEPT
- A. mechanical ventilation use.
- B. complex medication regimen.
- C. isolation precaution requirements.
- D. nurse-to-client ratio.
Correct Answer: D
Rationale: Nurse-to-client ratio is a staff-related factor, affecting workload distribution. Ventilation, medications, and isolation are patient-specific needs.
You may also like to solve these questions
A client with bipolar disorder is discharged with a prescription for Depakote (divalproex sodium). The nurse should remind the client of the need for:
- A. Frequent dental visits
- B. Frequent lab work
- C. Additional fluids
- D. Additional sodium
Correct Answer: B
Rationale: Depakote requires regular lab monitoring (e.g., liver function, platelet counts) to detect potential side effects like hepatotoxicity or thrombocytopenia.
The client is admitted to the hospital with hypertensive crises. Diazoxide (Hyperstat) is ordered. During administration, the nurse should:
- A. Utilize an infusion pump
- B. Check the blood glucose level
- C. Place the client in Trendelenburg position
- D. Cover the solution with foil
Correct Answer: B
Rationale: Diazoxide can cause hyperglycemia, so monitoring blood glucose levels is essential during administration.
The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:
- A. Body image disturbance related to swelling of neck
- B. Anxiety-related changes in body image
- C. Altered nutrition, less than body requirements, related to difficulty in swallowing
- D. Risk for ineffective airway clearance related to pressure on the trachea
Correct Answer: D
Rationale: A goiter can compress the trachea, posing a risk for airway obstruction, making ineffective airway clearance the priority nursing diagnosis.
The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?
- A. place the client in restraints or mitts
- B. tell the family that they need to stay with the client
- C. replace the IV and wrap it in gauze to hide it from view
- D. tell the client that if she pulls another IV out, she will have to have a PICC line placed
Correct Answer: C
Rationale: Wrapping the IV in gauze hides it from view, reducing the likelihood of the client pulling it out, while being less invasive than restraints or threats.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth.
- B. The medication will be needed throughout the child's lifetime.
- C. The medication schedule can be arranged to allow for drug holidays.
- D. The medication is given one time daily every other day.
Correct Answer: B
Rationale: Congenital hypothyroidism requires lifelong thyroid hormone replacement therapy to maintain normal metabolism and development.