Nokea
The first standard step in oxygen therapy that the nurse should do is________.
- A. assess client's condition
- B. gather all the equipment and supplies
- C. prepare the client for the oxygen treatment
- D. check the chart for ordered flow rate and oxygen delivery method
Correct Answer: A
Rationale: The first standard step in oxygen therapy that the nurse should do is to assess the client's condition. Before initiating any oxygen treatment, it is essential to assess the client's respiratory status, oxygen saturation levels, vital signs, and overall condition. This initial assessment helps the nurse to determine the appropriate course of oxygen therapy based on the client's individual needs and current health status. Assessing the client's condition first ensures that the oxygen therapy provided is safe and effective for the specific needs of the client.
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Which is not a correct statement regarding record-keeping?
- A. Failure to do it could be evidence of professional liability
- B. It is an optional task to be done when circumstances allow.
- C. It is a tool in professional practice that helps provide quality care.
- D. It is part of the professional duty of the nurse.
Correct Answer: B
Rationale: Record-keeping is not an optional task; it is a critical aspect of professional nursing practice. As a nurse, maintaining accurate and timely records is essential for providing quality care, ensuring legal and ethical standards are met, and promoting patient safety. Failure to keep thorough records can lead to serious consequences such as compromising patient care, violating regulations, and even facing legal consequences. Thus, record-keeping should be seen as a mandatory part of the professional duty of nurses rather than an optional task that can be done when circumstances allow.
A patient with a history of chronic kidney disease is prescribed erythropoietin-stimulating agents (ESAs) for anemia management. Which parameter should the nurse monitor closely during ESA therapy?
- A. Serum potassium levels
- B. Hemoglobin levels
- C. Serum creatinine levels
- D. White blood cell count
Correct Answer: B
Rationale: When a patient with chronic kidney disease is prescribed erythropoietin-stimulating agents (ESAs) for anemia management, the parameter that should be monitored closely by the nurse is the hemoglobin levels. Hemoglobin levels indicate the patient's response to ESA therapy and are essential in assessing the effectiveness of the treatment in addressing anemia. Monitoring hemoglobin levels helps ensure that the patient's anemia is controlled within the target range to avoid both the risks of under-treatment (resulting in persistent anemia) and over-treatment (increased risk of adverse outcomes such as hypertension, stroke, or cardiovascular events).
Delegation is a critical component of leadership and governance. Which of the following empowering activities should the unit manager applies in delegation?
- A. In delegation facilitating professional growth and development of a staff is necessary.
- B. When delegating responsibility to a nursing staff, modification of standards of care is permitted.
- C. Delegation of responsibility in patient care has to start from top management to the staff-nurse level.
- D. Delegation requires responsibility with corresponding accountability of a staff-nurse.
Correct Answer: A
Rationale: In delegation, facilitating the professional growth and development of a staff is necessary because it allows team members to gain new skills and experience, leading to overall improved productivity and job satisfaction. This empowers staff and helps them feel more engaged in their work, ultimately benefiting the entire unit. Effective delegation should aim to support individuals in their roles, encourage learning, and build competence, rather than modifying standards of care or only delegating tasks without considering individual growth. Starting delegation from top management to staff-nurse level may not always be practical or efficient, as delegation should be based on competencies and responsibilities. Accountability is indeed a crucial aspect of delegation, as individuals should be held responsible for the tasks they are delegated. However, without providing opportunities for professional growth and development, delegation may not be as effective in achieving organizational goals.
Which danger sign would warrant stoppage of pills?
- A. Clear vision
- B. Decrease blood pressure
- C. Simple colds
- D. Elevation of blood pressure
Correct Answer: D
Rationale: An elevation of blood pressure would warrant stoppage of pills. High blood pressure, or hypertension, in a 4-year-old child is abnormal and needs prompt medical attention. Giving pills without monitoring or stopping them if blood pressure is elevated can lead to serious health complications. It is important to address the underlying cause of high blood pressure in a child, which may require further evaluation and management by a healthcare provider.
A patient with heart failure is prescribed digoxin. Which electrolyte imbalance increases the risk of digoxin toxicity?
- A. Hyperkalemia
- B. Hypernatremia
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: C
Rationale: Hypokalemia (low levels of potassium) increases the risk of digoxin toxicity. This is because digoxin competes with potassium for binding sites on the sodium-potassium ATPase pump in the cell membrane. When potassium levels are low, there is an increased binding of digoxin to these pumps, leading to enhanced entry of calcium into the cells. This can result in an increased intracellular calcium concentration, leading to digoxin toxicity and potential cardiac arrhythmias. Therefore, monitoring and correcting potassium levels is crucial in patients prescribed digoxin to reduce the risk of toxicity.