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Which nursing actions are in response to the National Patient Safety Goals (select all that apply)?
- A. Use restraints to prevent patient falls
- B. Administer all medications ordered by physicians
- C. Wash hands before and after every patient contact
- D. Evaluate the initial existence of pressure ulcers before patient dismissal
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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How will recognizing that clients have different perceptions of time assist the nurse to provide more sensitive care?
- A. Adapting care plans to accommodate varying time perspectives.
- B. Enforcing strict schedules regardless of cultural differences.
- C. Ignoring time-related preferences.
- D. None of the above.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is wearing a Venturi mask to receive oxygen, and the dinner tray has arrived. What action by the nurse is best?
- A. Assess the client's oxygen saturation and, if normal, turn off the oxygen.
- B. Determine if the client can switch to a nasal cannula during the meal.
- C. Have the client lift the mask off the face when taking bites of food.
- D. Turn off the oxygen while the client eats the meal and then restart it.
Correct Answer: B
Rationale: The correct answer is B: Determine if the client can switch to a nasal cannula during the meal. This is the best action because the client can maintain oxygen therapy while eating without the obstruction of the Venturi mask. Switching to a nasal cannula allows for continued oxygen delivery during meals.
A: Assessing the client's oxygen saturation and turning off the oxygen if normal is incorrect because the client still needs oxygen support during meals.
C: Having the client lift the mask off the face when taking bites of food is incorrect as it disrupts continuous oxygen therapy.
D: Turning off the oxygen while the client eats the meal and then restarting it is incorrect as it interrupts oxygen therapy, which should be continuous for clients requiring oxygen support.
A healthcare professional is caring for four clients on intravenous heparin therapy. Which lab value possibly indicates a serious side effect has occurred?
- A. Hemoglobin: 14.2 g/dL
- B. Platelet count: 82,000/µL
- C. RBC count: 4.8 x 10^6/µL
- D. WBC count: 8.7 x 10^3/µL
Correct Answer: B
Rationale: The correct answer is B: Platelet count: 82,000/µL. A low platelet count (thrombocytopenia) is a serious side effect of heparin therapy, as it can lead to bleeding complications. Platelets are essential for normal blood clotting. Hemoglobin, RBC count, and WBC count are not directly affected by heparin therapy and do not indicate a serious side effect.
Why should a nurse practice caution when changing the wound dressings of a client who underwent surgery?
- A. To avoid damaging new tissue.
- B. To avoid causing pain to the client.
- C. To fasten the wound healing.
- D. To avoid wound infection.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An 83-year-old woman is being discharged from the hospital following stabilization of her international normalized ratio (INR) levels (used to assess effectiveness of warfarin therapy). She has chronic atrial fibrillation and has been on warfarin (Coumadin) for several years. Discharge instructions include returning to the clinic weekly for INR testing. Which statement by the patient indicates that she may be unable to have the testing done?
- A. When I have the energy
- B. I have taken the bus to get this test done.
- C. I will need to ask my son to bring me into town every week for the test.
- D. Should I just keep taking the same pill every day until I can get a ride to town?
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.