Nokea
The nurse has a client who is being transferred to another floor right around change of shift. Which of the following actions is least appropriate?
- A. Inform the staff on the other floor of any unresolved issues with the client.
- B. Ask the charge nurse if overtime would be permitted to complete the client's transfer to the other floor.
- C. Ask the new nurse to take care of the transfer since the client's medical record has all of the information, and a report should not be needed.
- D. Complete the transfer paperwork before the client is transferred.
Correct Answer: C
Rationale: The least appropriate action in this scenario is to ask the new nurse to take care of the transfer without providing a full handoff of care. It is crucial to ensure a safe handoff during the transfer to maintain continuity of care and patient safety. Informing the staff on the other floor of any unresolved issues with the client (Choice A) is important for the client's well-being as it helps in providing comprehensive care. Asking the charge nurse about overtime (Choice B) demonstrates consideration for completing the task effectively, but it should not take precedence over ensuring a proper handoff. Completing the transfer paperwork before the client is transferred (Choice D) is necessary to ensure all documentation is in order, but it should be done in conjunction with providing a thorough handoff of care to the new nurse.
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A 65-year-old female client is experiencing postmenopausal bleeding. Which type of physician should this client be encouraged to see?
- A. a radiologist
- B. a gynecologist
- C. a physiatrist
- D. an oncologist
Correct Answer: B
Rationale: A 65-year-old female experiencing postmenopausal bleeding should be encouraged to see a gynecologist. Gynecologists specialize in treating and managing diseases of the female reproductive organs, making them the most appropriate physician for this issue. Postmenopausal bleeding can indicate various gynecological conditions such as endometrial atrophy, endometrial hyperplasia, or endometrial cancer, highlighting the importance of consulting a gynecologist for proper diagnosis and management. Radiologists evaluate X-rays, physiatrists manage rehabilitation teams, and oncologists treat clients with cancer. Therefore, in this case, the symptoms point towards a gynecological problem, emphasizing the necessity of seeking care from a gynecologist.
When inspecting the client's eyelids for ptosis, the nurse is checking for which abnormality?
- A. Drooping
- B. Pupil dilation
- C. Pupil constriction
- D. Deviation of ocular movements
Correct Answer: A
Rationale: When a nurse inspects a client's eyelids for ptosis, they are checking for drooping. Ptosis is a condition characterized by the drooping of the eyelids and can be associated with various disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell's palsy. Pupil dilation and constriction are assessed using a flashlight to check pupillary response. Deviation of ocular movements is evaluated by leading the client's eyes through the six cardinal positions of gaze. Therefore, in this scenario, the correct answer is 'Drooping' as it specifically relates to the abnormality associated with ptosis.
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
- A. The physician in charge of the case is the sole person allowed to decide whether organ donation can occur.
- B. The client's legally responsible party may make the decision for organ donation for the donor if the client is unable to do so.
- C. The organ procurement organization makes the decision regarding which organs to harvest.
- D. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process.
Correct Answer: A
Rationale: While the physician plays a crucial role in the process of organ donation, they are not the sole decision-maker. The client's legally responsible party may make the decision for organ donation if the client is unable to do so. Additionally, the organ procurement organization is responsible for determining which organs are suitable for donation. Therefore, the statement that the physician in charge is the sole person allowed to decide whether organ donation can occur is incorrect. The correct answer is A. Choices B, C, and D are true statements as they highlight the involvement of the legally responsible party, the organ procurement organization, and the donor/legally responsible party, physician, and organ-procurement organization in the organ donation process respectively.
In conducting a health screening for 12-month-old children, the nurse expects them to have been immunized against which of the following diseases?
- A. measles, polio, pertussis, hepatitis B
- B. diphtheria, pertussis, polio, tetanus
- C. rubella, polio, pertussis, hepatitis A
- D. measles, mumps, rubella, polio
Correct Answer: B
Rationale: By 12 months of age, children should have received vaccines for diphtheria, pertussis, polio, and tetanus (DTaP and IPV). The correct answer is B as it includes these vaccines that are typically administered in the first year of life. Measles, mumps, and rubella (MMR) vaccination usually begins at 12 months of age but is not expected to be completed by this time. Choices A and C are incorrect as they include diseases that are not part of the routine immunization schedule for a 12-month-old child.
When assessing Mr. Lee's eye condition, what general information should the nurse seek?
- A. Type of employment.
- B. Burning or itchy sensation in the eyes.
- C. Position of the eyelids.
- D. Existence of floaters.
Correct Answer: A
Rationale: When assessing a patient's eye condition, the nurse should seek general information such as the type of employment, activities, allergies, medications, lenses, and protective devices used. This information helps in understanding potential exposures to irritants and risks related to activities. While the presence of burning or itchy sensation in the eyes, position of the eyelids, and existence of floaters are important aspects to assess during a focused eye examination, during the initial assessment, the type of employment is more relevant for understanding possible environmental factors affecting eye health.