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A nurse who plans care based on the patient’s gender, ethn ai bc iri bt .y co, ms /p tei sr ti tuality, and lifestyle is said to demonstrate what focus?
- A. Becoming a moral advocate.
- B. Facilitating all forms of learning.
- C. Responding to diversity.
- D. Using effective clinical judgment.
Correct Answer: C
Rationale: The correct answer is C: Responding to diversity. By considering the patient's gender, ethnicity, spirituality, and lifestyle, the nurse is focusing on responding to diversity in patient care. This approach acknowledges and respects the unique characteristics and backgrounds of individual patients, leading to more culturally competent and effective care.
Choice A: Becoming a moral advocate does not directly relate to considering diversity in patient care. It involves standing up for ethical principles and values in healthcare.
Choice B: Facilitating all forms of learning is not specific to addressing diversity in patient care. It pertains to promoting education and understanding in various learning styles.
Choice D: Using effective clinical judgment is important in nursing practice but does not specifically address the focus on diversity in patient care. It pertains to making sound decisions based on clinical knowledge and expertise.
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The nurse is caring for a client who is unable to void. The plan of care establishes an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document that indicates a successful outcome?
- A. Demonstrates adequate fluid intake and output.
- B. Verbalizes abdominal comfort without pressure.
- C. Drinks 240 mL of fluid five times during the shift.
- D. Voids at least 1000 mL between 7 am and 3 pm.
Correct Answer: C
Rationale: Step 1: The objective is for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm.
Step 2: Choice C states that the client drinks 240 mL of fluid five times during the shift, totaling 1200 mL (240 mL x 5) which exceeds the required amount.
Step 3: Therefore, choice C is the correct answer as it demonstrates successful achievement of the objective by ensuring the client has ingested enough fluid within the specified time frame.
Step 4: Choices A, B, and D are incorrect as they do not directly address the specific objective of fluid intake set for the client. Option A focuses on intake and output, option B relates to abdominal comfort, and option D is about voiding, none of which directly address the specified objective of fluid ingestion.
The nurse is caring for a patient who has a temporary percutaneous dialysis catheter in place. In caring for this patient, the nurse should
- A. apply a sterile gauze dressing to maintain sterility.
- B. replace the transparent dressing every 10 days to prevent manipulation.
- C. assess the catheter site for redness and/or swelling.
- D. use the catheter for drawing blood samples to reduce patient discomfort.
Correct Answer: C
Rationale: The correct answer is C because assessing the catheter site for redness and/or swelling is crucial for early detection of infection. Redness and swelling are common signs of infection at the catheter site, which requires prompt intervention. Applying a sterile gauze dressing (choice A) is not necessary for a temporary percutaneous dialysis catheter. Replacing the transparent dressing every 10 days (choice B) is not recommended as it can increase the risk of infection. Using the catheter for drawing blood samples (choice D) is not appropriate as it can introduce contaminants and increase the risk of infection. Regular assessment of the catheter site is essential for early detection and prevention of complications.
The family of your critically ill patient tells you that they h ave not spoken with the physician in over 24 hours and they have some questions that they w ant clarified. During morning rounds, you convey this concern to the attending intensivist and arrange for her to meet with the family at 4:00 PM in the conference room. Which com petency of critical care nursing does this represent?
- A. Advocacy and moral agency in solving ethical issues
- B. Clinical judgment and clinical reasoning skills
- C. Collaboration with patients, families, and team membe rs
- D. Facilitation of learning for patients, families, and team members
Correct Answer: C
Rationale: The correct answer is C: Collaboration with patients, families, and team members. By addressing the family's concern about lack of communication with the physician and arranging a meeting between the intensivist and the family, the nurse is demonstrating collaboration skills in facilitating communication and ensuring the family's questions are addressed. This competency emphasizes the importance of working together with patients, families, and the healthcare team to provide optimal care.
Incorrect choices:
A: Advocacy and moral agency in solving ethical issues - While advocacy is important in nursing, in this scenario, the focus is on communication and collaboration rather than ethical issues.
B: Clinical judgment and clinical reasoning skills - Although these skills are crucial in critical care nursing, the situation described does not primarily involve clinical judgment but rather communication and collaboration.
D: Facilitation of learning for patients, families, and team members - While patient education is important, the main focus of the scenario is on addressing the family's concerns and facilitating communication, rather than educational aspects.
The nurse is caring for a patient who has an intra-aortic balloon pump in place. Which action should be included in the plan of care?
- A. Position the patient supine at all times.
- B. Avoid the use of anticoagulant medications.
- C. Measure the patient’s urinary output every hour.
- D. Provide a massive range of motion for all extremities.
Correct Answer: C
Rationale: The correct answer is C: Measure the patient’s urinary output every hour. This is crucial because monitoring urinary output is essential in assessing the patient’s renal function and the effectiveness of the intra-aortic balloon pump in improving cardiac output. Hourly measurement helps in early detection of any changes that may indicate complications.
A: Positioning the patient supine at all times is not necessary and can lead to complications.
B: Avoiding the use of anticoagulant medications is not appropriate as they are often necessary to prevent clot formation around the balloon pump.
D: Providing a massive range of motion for all extremities is not recommended for a patient with an intra-aortic balloon pump as it can dislodge the device or cause harm.
During a client assessment, the client says, 'I can't walk very well.' Which action should the nurse implement first?
- A. Predict the likelihood of the outcome.
- B. Consider alternatives.
- C. Choose the most successful approach.
- D. Identify the problem.
Correct Answer: D
Rationale: The correct answer is D: Identify the problem. This is the first action the nurse should take in the nursing process as it helps in understanding the client's issue. By identifying the problem, the nurse can gather more information through further assessment to determine the underlying cause of the client's difficulty in walking. This step is crucial for developing an effective care plan and interventions.
A: Predict the likelihood of the outcome - This choice is not appropriate as predicting the outcome should come after identifying the problem and implementing interventions.
B: Consider alternatives - While considering alternatives is important in the decision-making process, it is not the immediate action needed in this scenario.
C: Choose the most successful approach - This choice is premature as the nurse needs to first identify the problem before determining the most successful approach.