When should discharge planning begin for a patient in a tertiary-care facility?
- A. On the day of admission
- B. After the acute crisis is resolved
- C. When the physician writes the discharge order
- D. When the patient demonstrates readiness to discuss posthospitalization needs
Correct Answer: A
Rationale: Rationale:
A: Discharge planning should begin on the day of admission to ensure a smooth transition. This early start allows for comprehensive assessment and coordination of post-discharge needs.
B: Waiting until after the acute crisis is resolved may lead to rushed planning and potential gaps in care.
C: Discharge planning should not solely rely on the physician's discharge order as it may not address all aspects of the patient's needs.
D: Patient readiness is important, but starting planning early ensures sufficient time for assessment and interventions.
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Priority Decision: When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next?
- A. Note this information in the patient's record as hay fever and food allergies.
- B. Place an allergy alert wristband that identifies the specific allergies on the patient.
- C. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.
- D. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.
Correct Answer: C
Rationale: Understanding the nature and severity of allergies helps in planning appropriate perioperative care and avoiding potential allergens.
If the SpO2 level is above 90%, what can be assumed about the PaO2?
- A. Hypoxia
- B. Hypercapnia
- C. Acidosis
- D. Alkalosis
Correct Answer: C
Rationale: Acidosis occurs when blood pH drops below 7.35 due to an accumulation of hydrogen ions, commonly resulting from respiratory or metabolic imbalances.
Which chief complaint is NOT desirable for recording on the client’s chart?
- A. CC: “cough and temperature elevation,” 2 days duration
- B. CC: “passing black stools,” 1 day duration
- C. CC: “substernal pain,” 2 hours duration
- D. Reason for contact: “physical examination for college”
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Chief complaints should be symptoms or concerns related to the client's health issues.
2. "Physical examination for college" is not a specific symptom or health concern.
3. Chief complaints guide healthcare providers in assessing and treating the client.
4. Recording irrelevant chief complaints can lead to confusion in diagnosis and treatment.
Summary of Incorrect Choices:
A: Describes specific symptoms, suitable for recording.
B: Describes a specific symptom (black stools), suitable for recording.
C: Describes a specific symptom (substernal pain), suitable for recording.
Patients with a paralytic ileus typically have
- A. Intravenous fluid replacement and a nasogastric tube connected to suction.
- B. Surgical correction of the problem.
- C. Endoscopic injection of botulinum toxin or esophageal dilation.
- D. Endoscopy to allow biopsy followed with broad-spectrum antibiotics.
Correct Answer: A
Rationale: Paralytic ileus requires decompression of the gastrointestinal tract.
Which task is appropriate to delegate to the nursing assistant?
- A. Chest compressions
- B. Bag-valve mask ventilation
- C. Assisting with oral intubation
- D. Placing the defibrillator pads
Correct Answer: A
Rationale: Chest compressions are a physical task that can be delegated to a nursing assistant under supervision.