Nokea
To manage time most effectively, the nurse responds to which of the following stimuli first:
- A. the physician's loud verbal direction.
- B. the nursing supervisor who is going to a meeting.
- C. unit staff leaving on a break.
- D. the care needs of the returning postoperative client just exiting the elevator.
Correct Answer: D
Rationale: While many environmental stimuli might compete for attention and time, the client care needs of complex or unstable clients and those requiring assessment and care must take priority.
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An advance directive is written and notarized according to law in the state of Colorado. This document is legal and binding:
- A. internationally.
- B. in the state of Colorado only.
- C. in the continental United States.
- D. in the county of origination only.
Correct Answer: B
Rationale: Advance directive protocols and documents are defined by each state.
Which is the best way to position a client's neck for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct Answer: A
Rationale: Flexing the neck toward the side being examined relaxes the sternocleidomastoid muscle, making the thyroid gland more accessible for palpation.
A client being treated for sickle cell disease has an order for pain medication. Morphine was ordered, but the nurse is having difficulty deciphering the dose. The nurse should
- A. ask the attending physician to come back to the unit and to help read what the order states regarding the correct medication, dose, route, and frequency
- B. call the charge nurse to reach out to the attending physician to verify the order including the correct medication, dose, route, and frequency
- C. call the attending physician to verbally verify the order including correct medication, dose, route, and frequency
- D. just go with his or her gut on what the typical dose is for this medication and administer to the client so they do not have to wait on the physician
Correct Answer: C
Rationale: It is the nurse's responsibility to fully comprehend an attending physician's order prior to carrying it out. This includes verifying any confusing or indiscernible directions/orders via calling or discussing in person with the attending physician.
An LPN is talking with a client scheduled to undergo a vasectomy in the next few minutes. He states, 'I know I signed the form and all, but I'm not feeling so sure of this. It can be reversed pretty easily, right?' What is the LPN's best response?
- A. Yes, vasectomies can be reversed, but I'm sure once you have it you won't regret it.'
- B. It's normal to feel a little nervous before a procedure like this one.'
- C. It sounds like you have a few more questions you'd like answered. Let me grab the doctor to answer them for you.'
- D. It sounds like you might be a little nervous. Don't worry, this is a pretty minor procedure, and the doctor doing it is the best we have. You're in great hands.'
Correct Answer: C
Rationale: This is the only option that validates the client's concerns and also respects his right to informed consent.
A newborn baby exhibits a reflex that includes: hand opening, abducted and extended extremities following a jarring motion. Which of the following correctly identifies the reflex?
- A. ATNR reflex
- B. Startle reflex
- C. Grasping reflex
- D. Moro reflex
Correct Answer: D
Rationale: The moro reflex has all of the listed characteristics.