Nokea
The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. The unit director should initiate which of the following actions? Select all that apply.
- A. Identify the problem at a staff meeting without placing blame on any individual or group.
- B. Ask the unit staff to develop a plan that they think will solve this problem.
- C. Ask an experienced nurse to spend time reorienting newer staff members.
- D. Collaborate with the staff development educator to develop a plan.
- E. Ask the neonatologist to give a presentation about assessing newborns.
Correct Answer: A,C,D,E
Rationale: Addressing the issue without blame, involving staff in solutions, reorienting newer staff, collaborating with educators, and arranging expert presentations are all effective strategies to improve documentation.
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The nurse is assessing a client with suspected pulmonary edema. Which of the following findings would support this diagnosis?
- A. Crackles in the lung bases.
- B. Bradypnea.
- C. Hypotension.
- D. Dry cough.
Correct Answer: A
Rationale: Crackles in the lung bases indicate fluid accumulation in pulmonary edema.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min via nasal cannula. The client's oxygen saturation is 88%. What should the nurse do first?
- A. Increase the oxygen to 4 L/min
- B. Encourage deep breathing exercises
- C. Notify the respiratory therapist
- D. Assess the client's respiratory status
Correct Answer: D
Rationale: An oxygen saturation of 88% is low for a COPD client, but increasing oxygen without assessment risks CO2 retention. Assessing respiratory status first guides appropriate intervention.
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
An adult client has been placed on a fluid restriction of 1200 mL per day. The nurse discusses the fluid restriction with the dietitian and then plans to allow the client to have how many milliliters of fluid from 7:00 am to 3:00 pm?
- A. 400 mL
- B. 600 mL
- C. 800 mL
- D. 1000 mL
Correct Answer: B
Rationale: When a client is on fluid restriction, the nurse informs the dietary department and discusses the allotment of fluid per shift with the dietitian. When calculating how to distribute a fluid restriction, the nurse usually allows half of the daily allotment (600 mL) during the day shift, when the client eats two meals and takes most medications. Another two-fifths (480 mL) is allotted to the evening shift, with the balance (120 mL) allowed during the nighttime.
A diabetic client who takes insulin is being seen by the nurse for a low blood glucose level. Which of the following would be the best choices to begin to raise the blood glucose level? Select all that apply.
- A. One-half cup of orange juice.
- B. One cup of milk.
- C. One ounce of tuna.
- D. One tablespoon of peanut butter.
- E. One piece of bread.
- F. One-half cup of regular soda.
Correct Answer: A, B, E, F
Rationale: Orange juice, milk, bread, and regular soda contain fast-acting carbohydrates to raise blood glucose quickly.