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In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?
- A. Ensure sterilization of nondisposable items with ethylene oxide.
- B. Wear hypoallergenic latex gloves that do not contain powder.
- C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
- D. Wrap monitoring cords with stockinette and tape them in place.
Correct Answer: B
Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. This is the best precaution because it minimizes the risk of the client having an allergic reaction to latex during the procedure. Powdered latex gloves can release latex particles into the air, increasing the likelihood of a reaction. Hypoallergenic gloves are designed to reduce the risk of allergic responses.
Choice A is incorrect as ethylene oxide is used for sterilization of medical equipment, not specifically for latex allergy precautions. Choice C is incorrect because cleansing latex ports with chlorhexidine does not address the risk of latex exposure. Choice D is also incorrect as wrapping monitoring cords does not directly address the issue of latex allergy.
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Achieving Magnet Hospital designation offers hospitals the following advantages: (Select all that apply.)
- A. Greater client satisfaction.
- B. Improved nursing recruitment.
- C. Greater client workload.
- D. Nurses who are independent decision makers.
Correct Answer: C
Rationale: The correct answer is C: Greater client workload. Magnet Hospitals are known for their commitment to nursing excellence, which leads to improved patient outcomes and increased demand for their services. This higher demand can result in a greater client workload for the hospital. The other choices are incorrect because A (Greater client satisfaction) and B (Improved nursing recruitment) are potential benefits of Magnet Hospital designation, but they are not guaranteed advantages. Choice D (Nurses who are independent decision makers) is not directly related to the advantages of achieving Magnet Hospital designation. Therefore, the correct answer is C as it aligns with the core principles of Magnet Hospitals.
1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select one that doesn't apply)?
- A. Blood pressure
- B. Serum creatinine
- C. Chest x-ray
- D. Urine for microalbuminuria
Correct Answer: C
Rationale: Step-by-step rationale for correct answer (C):
1. Chest x-ray is not routinely recommended for monitoring complications of type 2 diabetes.
2. Annual blood pressure monitoring is crucial for assessing cardiovascular risk in diabetic patients.
3. Serum creatinine test helps evaluate kidney function, which is often impaired in diabetes.
4. Urine microalbuminuria test detects early signs of kidney damage, common in diabetes.
Summary of incorrect choices:
A: Blood pressure monitoring is essential for assessing cardiovascular risk in diabetes.
B: Serum creatinine test is important for evaluating kidney function in diabetic patients.
D: Urine microalbuminuria test helps detect early kidney damage in diabetes.
A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?
- A. Validate the client's feelings by saying, 'People in middle adulthood often find satisfaction in nurturing and guiding young people.'
- B. Encourage the client to explore the reasons behind feeling useless.
- C. Reassure the client by saying, 'You should be proud that your children are becoming independent.'
- D. Provide information by saying, 'Most people are happy when their children grow up and leave home.'
Correct Answer: A
Rationale: The correct answer is A because it validates the client's feelings by acknowledging the common experience of middle adults feeling a sense of purpose through nurturing others. This response shows empathy and understanding, which can help the client feel heard and supported.
Choice B is incorrect because it immediately delves into exploring the reasons behind the feelings without first acknowledging or validating them. This approach may come off as dismissive or insensitive.
Choice C is incorrect because it brushes off the client's feelings by emphasizing the positive aspect of children becoming independent, without addressing the client's emotional distress.
Choice D is incorrect because it makes a generalization about happiness related to children leaving home without directly addressing the client's specific feelings of uselessness. It does not acknowledge or validate the client's emotions.
Achieving Magnet Hospital designation offers hospitals the following advantages: (Select one that does not apply.)
- A. Greater client satisfaction.
- B. Improved nursing recruitment.
- C. Greater client workload.
- D. Nurses who are independent decision makers.
Correct Answer: C
Rationale: The correct answer is C: Greater client workload. Achieving Magnet Hospital designation typically does not lead to an increase in client workload. The other choices (A, B, D) are advantages of Magnet Hospital designation as they are commonly associated with it. A: Greater client satisfaction is a common outcome due to improved quality of care. B: Improved nursing recruitment is a benefit as it attracts high-quality nurses. D: Nurses who are independent decision makers is a characteristic of Magnet Hospitals, promoting autonomy and professional growth.
An RN’s client with terminal pancreatic cancer asks questions about a do not resuscitate order. Which of the following statements should be included in the RN’s teaching to the client?
- A. When a heart ceases to beat, the client is pronounced clinically dead.
- B. Physicians must write do not resuscitate (DNR) orders.
- C. A DNR order can be written after the health-care provider has discussed it with the client and family.
- D. A DNR requires a court decision.
Correct Answer: C
Rationale: Rationale for Correct Answer C:
1. In terminal cases, it's crucial for the healthcare provider to discuss DNR orders with the client and family to ensure understanding and consent.
2. The decision to implement a DNR order should always involve the client and their family to respect their wishes.
3. This statement emphasizes the importance of communication and shared decision-making in end-of-life care.
Summary:
A: Incorrect - This statement is about the clinical definition of death, not about DNR orders.
B: Incorrect - While physicians can write DNR orders, the involvement of the client and family is essential.
D: Incorrect - DNR orders do not require a court decision; they are typically based on the client's wishes and discussions with healthcare providers.