Nokea
The nurse is reinforcing instructions about the use of regular and neutral protamine Hagedorn (NPH) insulin. Which statement by the client indicates that further instruction is needed?
- A. I will always check my blood glucose prior to using the sliding scale.
- B. I will eat breakfast 30 minutes after taking my morning NPH and regular insulin.
- C. I will use a new insulin syringe each time I give myself an injection.
- D. I will use the sliding scale to determine my NPH dose 4 times a day.
Correct Answer: B
Rationale: Eating 30 minutes after NPH and regular insulin (B) risks hypoglycemia, as regular insulin acts within 30 minutes. Checking glucose (A), using new syringes (C), and sliding scale for regular insulin (D) are correct.
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A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, 'What would you do if this was your family member?' How should the nurse respond?
- A. I'm not sure what I would do, but I feel confident that you will make the right decision.
- B. I will call the chaplain to help you sort through the options and discuss the issue.
- C. What do you think are the advantages and disadvantages of a feeding tube?
- D. You should meet with the family to discuss what the patient would have wanted.
Correct Answer: C
Rationale: Exploring pros and cons (C) empowers the MPOA to make an informed decision. Personal opinions (A), chaplain referral (B), or family meetings (D) are less direct.
The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate?
- A. Tell the family they can bring in a pizza if the patient would prefer that.
- B. Make sure the patient gets at least 2 cartons of milk
- C. Stop the IV if the patient is able to eat solid food.
- D. Encourage the patient to eat slowly to prevent gas.
Correct Answer: D
Rationale: The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the task and how to promote the best outcome.
The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require the precepting nurse to intervene?
- A. Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu
- B. Lifts the traction weights while the unlicensed assistive personnel provide a bed bath and linen change
- C. Monitors the incision and pin insertion sites for erythema, drainage, and malodor
- D. Performs Doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery
Correct Answer: B
Rationale: Lifting traction weights (B) disrupts alignment and healing, requiring intervention. Hydration and fiber (A), monitoring sites (C), and pulse checks (D) are appropriate.
The wife of a 65 -year-old man says to the clinic nurse, 'I think the doctor should check out my husband's hearing. Either he is totally ignoring me and everyone else or he has a hearing problem.' How is the man likely to respond when the nurse asks him if he has difficulty hearing?
- A. I can hear women better than men.
- B. There's nothing wrong with my hearing. People around me just mumble a lot.
- C. I really need to get my hearing checked.
- D. Why should an old man like me care if he hears or not?
Correct Answer: B
Rationale: People who are losing their hearing usually complain that the people around them mutter. Denial is a very common response to hearing loss. Most older people who are having difficulties with hearing wait years before they will admit to hearing loss and accept treatment. Most older people who are losing their hearing hear lower frequencies (men's voices) better than higher frequencies (women's voices). Answer 4 not only indicates denial, but it also suggests that the client is in despair as opposed to ego integrity.
A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first
- A. support the planning committee and post the new schedule
- B. explore how the planning committee evaluated barriers to the plan
- C. design a different approach to deliver care with fewer staff
- D. retain the previous staffing pattern for another 6 months
Correct Answer: B
Rationale: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated.