Nokea
The nurse manager has a nurse employee who is suspected of a problem with chemical dependency. Which intervention would be the best approach by the nurse manager?
- A. Confront the nurse about the suspicions in a private meeting
- B. Schedule a staff conference, without the nurse present, to collect information
- C. Consult the human resources department about the issue and needed actions
- D. Counsel the employee to resign to avoid investigation
Correct Answer: C
Rationale: Consult the human resources department about the issue and needed actions. To avoid legal repercussions, the nurse needs to consult with the human resources department for proper procedure for documentation, counseling and available resources.
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Which of the following provides the best evidence that the nursing interventions to deal with a client’s self-care deficit in relation to feeding have been effective?
- A. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day.
- B. The client’s dentures have been replaced, and he is able to chew.
- C. The client will eat without verbalizing suspicions when a particular nurse sits with him.
- D. The client appears to have increased energy to complete grooming activities.
Correct Answer: A
Rationale: Eating half of meals and drinking 2,000 mL/day is a concrete measure of adequate nutrition, indicating effective interventions. Options B, C, and D are less direct: dentures aid chewing but don’t ensure intake, suspicions suggest unresolved issues, and grooming energy is unrelated.
The nurse is caring for a client with a fractured femur in traction.
- A. What is the most appropriate action for the nurse if the client reports numbness in the affected leg?
- B. Reposition the traction weights.
- C. Check the pin sites for infection.
- D. Assess the neurovascular status of the leg.
- E. Administer pain medication as ordered.
Correct Answer: C
Rationale: Numbness in the affected leg suggests possible neurovascular compromise, requiring immediate assessment of circulation, sensation, and motor function. Adjusting traction, checking pin sites, or giving pain medication does not address the urgent need to evaluate neurovascular status.
A diabetic client is taking Lantus insulin for regulation of his blood glucose levels. The nurse should know that this insulin will most likely be administered:
- A. Prior to each meal
- B. At night
- C. Midday
- D. Prior to the evening meal
Correct Answer: B
Rationale: Lantus is a long-acting insulin typically administered at night to provide basal coverage. Options A, C, and D are incorrect for its dosing schedule.
When a client is having a general tonic clonic seizure, the nurse should
- A. Hold the client's arms at their side
- B. Place the client on their side
- C. Insert a padded tongue blade in client's mouth
- D. Elevate the head of the bed
Correct Answer: B
Rationale: Place the client on their side. This position maintains a patent airway and prevents aspiration.
The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.