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Which finding indicates a need to contact the health care provider before the nurse
administers metformin (Glucophage)?
- A. The patient’s blood glucose level is 174 mg/dL.
- B. The patient has gained 2 lb (0.9 kg) since yesterday.
- C. The patient is scheduled for a chest x-ray in an hour
- D. The patient’s blood urea nitrogen (BUN) level is 52 mg/dL.
Correct Answer: D
Rationale: The correct answer is D because an elevated BUN level of 52 mg/dL indicates potential kidney dysfunction, which is a contraindication for metformin due to the risk of lactic acidosis.
A: Blood glucose level of 174 mg/dL is slightly high but not a contraindication for metformin.
B: Weight gain is unrelated to metformin administration.
C: Chest x-ray does not directly impact metformin administration.
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A client experiences difficulty breathing after the change of shift. The nurse on duty discovers that the IVFs were infusing at a rate 10 times the calculated normal. After notifying the physician and correcting the rate, what should be the next step in the client's care?
- A. Notify family
- B. Discipline the previous nurse
- C. Complete an incident report
- D. Obtain legal consultation
Correct Answer: C
Rationale: The correct answer is C: Complete an incident report. This is the next step in the client's care because documenting the incident is crucial for quality improvement and patient safety. It helps identify the root cause, prevent future errors, and ensure accountability. Notifying the family (A) may be necessary but not the immediate next step. Disciplining the previous nurse (B) is not appropriate without a thorough investigation. Obtaining legal consultation (D) may be needed later but is not the immediate priority.
When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)?
- A. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery.
- B. Discuss the reason for the use of insulin therapy during the immediate postoperative period.
- C. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
- D. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.
Correct Answer: C
Rationale: The correct answer is C: Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
Rationale:
1. Administering insulin falls under the scope of practice for an LPN/LVN.
2. Administering lispro insulin before surgery helps maintain the patient's blood glucose within a safe range during the procedure.
3. LPN/LVNs are trained to administer medications safely and accurately.
Summary:
A: Communication with the circulating nurse requires critical thinking and interpretation, which may be beyond the scope of an LPN/LVN.
B: Discussing the reason for insulin therapy involves patient education and interpretation, which are typically responsibilities of a registered nurse.
D: Planning strategies to prevent hypoglycemia or hyperglycemia requires higher-level critical thinking and assessment skills, usually performed by a registered nurse.
As the definition of nursing evolved, which of the following nurse theorists focused on the uniqueness of nursing?
- A. Florence Nightingale
- B. Virginia Henderson
- C. Martha Rogers
- D. Abraham Maslow
Correct Answer: B
Rationale: Virginia Henderson is the correct answer because she emphasized the unique role of nursing in helping individuals achieve independence in meeting their basic needs. Henderson's theory focuses on the holistic approach to patient care, highlighting the importance of individualized care and the nurse's role in assisting patients to reach their optimal health potential.
Florence Nightingale, known as the founder of modern nursing, focused on sanitation and environmental factors in health care. Martha Rogers emphasized the interconnectedness of humans with their environment. Abraham Maslow is known for his hierarchy of needs theory, which is more aligned with psychology than nursing.
An RN is writing reminders for good documentation for the nurses on her staff. The purpose is to ensure nursing documentation is legally credible. Which of the following is a recommendation she should include in the reminders?
- A. Use shortcuts in documentation.
- B. Only use approved abbreviations.
- C. Documentation should be subjective.
- D. Document after care is provided.
Correct Answer: B
Rationale: The correct answer is B: Only use approved abbreviations. Using approved abbreviations helps prevent misinterpretation and errors in documentation, ensuring legal credibility. Shortcuts in documentation (A) can lead to incomplete or inaccurate information. Subjective documentation (C) may lack objectivity and legal validity. Documenting after care is provided (D) may result in memory bias and inaccuracies. Therefore, emphasizing the use of approved abbreviations is crucial for ensuring accurate, clear, and legally credible nursing documentation.
What is the primary role of a nurse in an interdisciplinary team?
- A. To lead the healthcare team
- B. To advocate for the patient
- C. To provide emotional support to the patient
- D. To ensure compliance with regulations
Correct Answer: B
Rationale: The correct answer is B: To advocate for the patient. Nurses play a crucial role in advocating for the best interests of patients by ensuring their needs are met, promoting informed decision-making, and safeguarding their rights. Advocacy involves communication, empowerment, and promoting patient-centered care. Leading the healthcare team (A) is typically the role of a healthcare provider such as a physician or a team leader, not specifically a nurse. Providing emotional support (C) is essential for nurses, but it is not their primary role in an interdisciplinary team. Ensuring compliance with regulations (D) is important but is more aligned with administrative roles rather than the primary role of a nurse in an interdisciplinary team.