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What can you expect from Marianne, who is currently at the ONSET stage of fever?
- A. Hot, flushed skin
- B. Increase thirst
- C. Convulsion
- D. Pale,cold skin
Correct Answer: D
Rationale: Fever's onset (chill phase) features vasoconstriction e.g., pale, cold skin as the body raises its setpoint. Hot, flushed skin (flush phase), thirst (later), or convulsions (hyperpyrexia) follow. Nurses expect this initial response e.g., shivering in Marianne, guiding warming measures, per fever physiology.
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When an LVN/LPN is working for a health-care organization that has professional liability insurance, the nurse needs to base a decision on whether to buy individual professional liability insurance on which of the following things?
- A. the possibility that the organization could countersue the nurse in a lawsuit
- B. the cost of professional liability insurance to the nurse
- C. the amount and type of coverage the health-care organization carries
- D. the number of hours worked and the type of nursing work
Correct Answer: A
Rationale: Deciding whether to purchase individual professional liability insurance as an LVN/LPN involves weighing personal risk, and the possibility of the organization countersuing the nurse in a lawsuit is a critical factor. Organizational insurance typically covers nurses acting within their scope, but if a lawsuit arises and the organization's interests diverge such as alleging nurse negligence they might countersue to deflect liability. Individual insurance provides independent protection, ensuring legal defense and coverage tailored to the nurse's needs. Cost, organizational coverage, and work hours are relevant but secondary; cost affects feasibility, coverage might leave gaps, and hours or work type influence risk but don't address the specific threat of a countersuit. This choice emphasizes proactive self-protection in a litigious environment, safeguarding the nurse's career and finances.
A client has a Staphylococcus infection in a decubitus ulcer. In this case, Staphylococcus is the:
- A. Host
- B. Agent
- C. Environment
- D. Disease
Correct Answer: B
Rationale: In the Agent-Host-Environment Model, Staphylococcus is the agent the causative factor triggering illness, here infecting a decubitus ulcer. The client is the host, whose skin integrity and immunity determine susceptibility. The environment bedridden conditions or hygiene sets the stage for infection. The disease is the resulting pathology, like the ulcer's worsening. This model dissects causation: Staphylococcus (bacteria) invades the host (client) in a conducive environment (immobility), driving nursing interventions cleaning wounds, repositioning to disrupt the triad. Understanding the agent's role guides targeted care, like antibiotics, breaking the infection cycle. It's a practical lens for nurses, pinpointing external triggers to prevent or manage illness effectively, especially in chronic wound scenarios.
Which assessment finding indicates a potential complication of immobility related to the respiratory system?
- A. Increased muscle strength
- B. Increased lung expansion
- C. Diminished breath sounds
- D. Normal respiratory rate
Correct Answer: C
Rationale: Diminished breath sounds signal a respiratory complication from immobility, suggesting poor ventilation or issues like atelectasis or pneumonia due to shallow breathing. Stronger muscles or expanded lungs indicate healthy function, not problems, while a normal breathing rate doesn't reveal underlying lung issues. Nurses auscultate for this to detect early respiratory decline, prompting interventions like repositioning or breathing exercises, ensuring timely action to safeguard oxygenation in immobile patients.
The nurse asked an aide to check Mr. Gary's vitals. This is an example of?
- A. Delegation
- B. Responsibility
- C. Malpractice
- D. Health policy
Correct Answer: A
Rationale: Asking an aide for vitals is delegation (A) task assignment, per definition. Responsibility (B) duty, malpractice (C) breach, policy (D) rules not delegation-specific. A fits the nurse's supervised task for Mr. Gary, making it correct.
The nurse does not take shortcuts for example failing to identify a client when administering medications. This is an example of critical thinking attitude:
- A. Responsibility and accountability
- B. Thinking independently
- C. Fairness
- D. Discipline
Correct Answer: A
Rationale: Responsibility and accountability as a critical thinking attitude mean adhering to standards and owning outcomes, like verifying a client's identity before medication to ensure safety. This reflects duty to the patient and profession, avoiding errors (e.g., wrong patient dosing). Thinking independently involves personal judgment, not just following protocol, which this nurse does by sticking to rules. Fairness ensures impartiality, not directly tied to identification steps. Discipline implies consistency, overlapping with responsibility, but lacks accountability's emphasis on answerability. By not cutting corners, the nurse upholds ethical and safety standards, embodying responsibility and accountability, critical for trust and precision in medication administration, a high-stakes nursing task.