Nokea
The ICU nurse caring for a client who has just been declared brain dead can expect to find evidence of the client's wishes regarding organ donation:
- A. on the client's driver's license.
- B. in the client's safety deposit box.
- C. in the client's last will and testament.
- D. on the client's insurance card.
Correct Answer: A
Rationale: In most states, indication of organ donor status is found on the client's driver's license, making it easily accessible for decision-making in critical situations like declaring brain death. Evidence in a last will and testament or a safety deposit box may not be promptly available. Information about organ donation is typically not included on insurance cards. The primary care physician's health record documentation could also be a relevant source for the ICU nurse. Therefore, the correct answer is finding evidence of the client's wishes regarding organ donation on the client's driver's license.
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The method of splinting is always dictated by:
- A. location of the injury and whether it is open or closed.
- B. the severity of the client's condition and the priority decision.
- C. the number of available rescuers and the type of splints.
- D. all of the above.
Correct Answer: B
Rationale: The correct answer is 'the severity of the client's condition and the priority decision.' When determining the method of splinting, it is crucial to consider the severity of the client's condition and make decisions based on their priority. Choice A is incorrect because while the location of the injury and whether it is open or closed are important factors, they do not always dictate the method of splinting. Choice C is incorrect as the number of available rescuers and the type of splints may impact the execution of splinting but do not solely dictate the method. Choice D is incorrect as it suggests that all the factors mentioned dictate the method, but in reality, the severity of the client's condition and the priority decision are the primary factors.
A nurse discharge planner is preparing a client for discharge from an acute care setting. The nurse assesses that skilled home care services are clinically indicated. This assessment is based on all of the following indicators except:
- A. the client has been admitted to the hospital three times in the last 2 months.
- B. the client has a Foley catheter.
- C. the client's family is available to care for him 24 hours a day.
- D. the client is ordered to continue IV antibiotics 5 days post discharge.
Correct Answer: V
Rationale: Family availability to provide care and assistance is not an indicator for skilled home care services. In fact, the nurse might see an opportunity for family education to meet the client's needs so that less community support is needed. This should be discussed and negotiated with the family. Frequent hospital readmissions indicate that the client has not been able to manage either due to condition instability or lack of care needs being met, which is a red flag for home care services to monitor and meet those needs appropriately. A Foley catheter requires home health care due to infection potential and care requirements. IV antibiotics also necessitate home care for maintaining line patency and assessing the site.
What is a significant point about Shigella that the nurse should acknowledge upon identifying it in a stool culture?
- A. People who have been in contact with the client need to be tested.
- B. Shigella is an airborne infection.
- C. Shigella is a bacteria sometimes found in stagnant water.
- D. The nurse should wear a one-way breathing apparatus when giving client care.
Correct Answer: C
Rationale: Shigella is a bacteria sometimes found in stagnant water. Transmission of Shigella is typically oral-fecal, so good hand washing and the use of gloves are the best means of prevention when caring for a client with Shigella. The bacteria can be found in food and water contaminated by fecal material. Incidences of Shigella are reportable in many states. Choices A, B, and D are incorrect. While it is important for close contacts to be aware and practice good hygiene, testing is not routinely indicated. Shigella is not an airborne infection; it is transmitted through contaminated food or water. A one-way breathing apparatus is not necessary for caring for a patient with Shigella; standard precautions, including handwashing and gloves, are sufficient.
Delegation of tasks to appropriate personnel allows the nurse to:
- A. ensure tasks are appropriately distributed.
- B. keep other members of the team productive.
- C. maintain tight control of all aspects of the workflow.
- D. recognize the importance of team members' roles.
Correct Answer: B
Rationale: Delegating tasks to appropriate personnel is essential for a nurse to keep other team members productive. By assigning tasks that align with the specific roles and responsibilities of team members, the nurse can enhance work effectiveness and efficiency. Option A is incorrect because delegation is not primarily about ensuring tasks are evenly distributed but rather about utilizing team members' skills effectively. Option C is incorrect as maintaining tight control of all aspects of the workflow can hinder teamwork and limit individual growth. Option D is incorrect because effective delegation involves empowering team members to make decisions within their scope of practice, rather than solely recognizing the importance of their roles.
Regardless of their practice area, nurses should be concerned with:
- A. all drug-resistant bacteria.
- B. microorganisms that are critical.
- C. transmission of microorganisms.
- D. overprescription of bacteriostatic drugs.
Correct Answer: C
Rationale: All nurses should be concerned with preventing the transmission of microorganisms to themselves and others. A primary way to achieve this is through asepsis. Nursing practice emphasizes providing a safe environment to shield clients, family, and healthcare providers from infections. Choices A, B, and D are incorrect. While drug-resistant bacteria, critical microorganisms, and overprescription of bacteriostatic drugs are important, nurses' primary focus should be on preventing microorganism transmission to ensure safety and well-being.