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To ensure client safety, a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning?
- A. Case manager - responsible for overseeing a case load of clients but does not provide direct client care
- B. Client educator
- C. Client advocate
- D. Supervisor
Correct Answer: D
Rationale: The correct answer is D: Supervisor. In this scenario, the nurse manager is acting as a supervisor to oversee and ensure the newly licensed nurse performs the straight catheterization correctly, following protocols, and maintaining client safety. A supervisor role involves monitoring and guiding staff in their duties to ensure quality care. Choices A, B, and C are incorrect. A case manager typically manages a case load of clients but does not provide direct care like in this situation. Client educator and client advocate roles do not directly relate to supervising or overseeing a procedure being performed by another nurse.
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While measuring a client's oral temperature using an electronic thermometer, what action should the nurse take?
- A. Assist the client with oral hygiene before taking the temperature.
- B. Inquire whether the client has smoked in the last 30 minutes.
- C. Connect the red tip probe to the thermometer unit.
- D. Position the probe tip against the client's buccal mucosa.
Correct Answer: B
Rationale: The correct action for the nurse to take when measuring a client's oral temperature using an electronic thermometer is to inquire whether the client has smoked in the last 30 minutes. Smoking can affect the accuracy of oral temperature readings. Providing oral hygiene (Choice A) is not directly related to ensuring accurate temperature measurement. Connecting the red tip probe (Choice C) is not specific to oral temperature measurement accuracy. Positioning the probe tip against the buccal mucosa (Choice D) is incorrect as oral temperature is typically measured under the tongue, not against the cheek.
In planning care for a premature infant with respiratory distress syndrome, nursing actions are based on the fact that the most likely cause of this problem stems from the infant's inability to
- A. Stabilize alveolar surface tension
- B. Maintain alveolar surface tension
- C. Promote normal pulmonary blood flow
- D. Regulate intra-cardiac pressure
Correct Answer: B
Rationale: The correct answer is B: Maintain alveolar surface tension. Respiratory distress syndrome in premature infants is often caused by a deficiency in surfactant, a substance that helps maintain alveolar surface tension. Without adequate surfactant, the alveoli collapse, making it difficult for the infant to oxygenate effectively. Choices A, C, and D are incorrect because stabilizing alveolar surface tension is not the issue, promoting normal pulmonary blood flow and regulating intra-cardiac pressure are not directly related to the pathophysiology of respiratory distress syndrome in premature infants.
A nurse is planning care for a client who had a stroke. What task should be assigned to the assistive personnel?
- A. Assist the client with a partial bed bath
- B. Measure the client's blood pressure after the nurse administers antihypertensive medications
- C. Use a communication board to ask what the client wants for lunch
- D. Feed the client
Correct Answer: A
Rationale: The correct answer is to assign the assistive personnel to assist the client with a partial bed bath. This task falls within the scope of practice for assistive personnel and is a common activity in caring for clients who have had a stroke. Choice B involves measuring blood pressure, which should be done by a licensed nurse. Choice C requires the use of a communication board, which can be done by any healthcare team member, not just assistive personnel. Choice D involves feeding the client, which may require assessment and intervention by a licensed nurse to ensure proper nutrition and safety.
What is the most important aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery?
- A. Demonstration of appropriate hand hygiene
- B. Explanation of wound care technique
- C. Review of signs and symptoms of infection
- D. Instructions for when to contact the healthcare provider
Correct Answer: A
Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.
The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?
- A. Place the chair at a right angle to the bed on the client's left side before moving.
- B. Assist the client to a standing position, then place the right hand on the armrest.
- C. Have the client place the left foot next to the chair and pivot to the left before sitting.
- D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Correct Answer: D
Rationale: The correct method for transferring an elderly client with left-sided weakness from the bed to the chair involves moving the chair parallel to the right side of the bed and standing the client on the right foot. This technique provides a stable and safe transfer by utilizing the stronger side of the client to support the transfer. Choices A, B, and C are incorrect because placing the chair at a right angle to the bed on the client's left side, assisting the client to a standing position and placing the right hand on the armrest, and having the client pivot to the left before sitting do not address the client's left-sided weakness and may increase the risk of falls or injuries.