Nokea
The nurse is caring for a client with a closed reduction of the left forearm. Which finding should be reported to the physician immediately?
- A. The client complains of pain at the site of the fracture
- B. The client's fingers are cool and pale
- C. The client's cast has a foul odor
- D. The client's radial pulse is 88 beats per minute
Correct Answer: B
Rationale: Cool, pale fingers post-left forearm closed reduction indicate circulatory compromise, possibly compartment syndrome, needing urgent reporting pain is expected, odor suggests infection (less acute), and pulse (88) is normal. Nurses assess neurovascular status, acting fast, preventing tissue damage in this orthopedic emergency.
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Small for gestational age and large for gestational age infants have polycythemia because of:
- A. Hypocalcemia
- B. Hypoglycemia
- C. Hypoxia
- D. Hypothermia
Correct Answer: C
Rationale: Polycythemia (high red blood cell count) in SGA and LGA infants relates to intrauterine conditions. Hypocalcemia (choice A) affects calcium, not blood cells. Hypoglycemia (choice B) is metabolic, common in both, but unrelated to polycythemia. Hypoxia (choice C) triggers erythropoietin release, increasing RBCs; SGA infants face placental insufficiency, LGA infants (e.g., diabetic mothers) experience transient hypoxia. Hypothermia (choice D) doesn't cause polycythemia. C is correct, as hypoxia drives this adaptation. Nurses monitor hematocrit, manage viscosity risks (e.g., dehydration), and support oxygenation, preventing complications.
The nurse double-checked Mr. Gary's meds to avoid mistakes. This is an example of?
- A. Safety
- B. Quality improvement
- C. Patient-centered care
- D. Telemedicine
Correct Answer: A
Rationale: Double-checking meds is safety (A) preventing harm, per care standards. QI (B) enhances, patient-centered (C) tailors, telemedicine (D) remote not error-specific. A fits safety's focus, making it correct.
After a month, Mr. Gary's wife started going to her old routine, She said 'Gary would want me to continue living my life' This is an example of what stage of grieving?
- A. Denial
- B. Anger
- C. Bargaining
- D. Acceptance
Correct Answer: D
Rationale: Resuming routine with 'Gary would want is acceptance (D), per Kubler-Ross peace with loss, moving forward. Denial (A), anger (B), and bargaining (C) resist or alter reality. Acceptance reflects her adjustment, making it correct.
When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?
- A. In order to get the care done for all assigned clients, the charting must be as brief as possible.
- B. The proper format, such as SOAP or PIE, as chosen by the hospital, must be adhered to.
- C. The chart is a legal document and may be all a nurse has to support care that was given if called to court.
- D. Clients need to be assessed and the care documented at least once every hour during the shift.
Correct Answer: C
Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.
The nurse reported Mr. Gary's fall to improve safety. This is an example of?
- A. Incident reporting
- B. Documentation
- C. Health promotion
- D. Care transition
Correct Answer: A
Rationale: Reporting a fall is incident reporting (A) adverse event log, per definition. Documentation (B) records, promotion (C) well-being, transition (D) moves not report-specific. A fits the nurse's action for Mr. Gary's safety, making it correct.