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Which nutritional assessment data should be collected to best reflect total muscle mass in an adolescent?
- A. Height in inches or centimeters.
- B. Weight in kilograms or pounds.
- C. Triceps skinfold thickness.
- D. Upper arm circumference.
Correct Answer: D
Rationale: The correct answer is 'Upper arm circumference.' Upper arm circumference is a better indicator of total muscle mass in adolescents compared to height, weight, or triceps skinfold thickness. Triceps skinfold thickness primarily reflects subcutaneous fat, while weight and height are not specific to muscle mass. Upper arm circumference directly measures the muscle mass in the upper arm and can provide a more accurate assessment in this context. Therefore, choices A, B, and C are incorrect because they do not directly reflect total muscle mass in adolescents.
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A nurse receives a prescription for an antibiotic for a client with cellulitis. The nurse checks the client's medical record, discovers the client's allergy to the antibiotic, and calls the provider for a different prescription. Which of the following critical thinking attitudes did the nurse demonstrate?
- A. Fairness
- B. Responsibility
- C. Risk-taking
- D. Creativity
Correct Answer: B
Rationale: The nurse demonstrated responsibility by recognizing the potential harm of administering an antibiotic the client is allergic to and taking the necessary steps to ensure the client's safety. Choice A, 'Fairness,' is not applicable in this scenario as it does not involve treating individuals equitably. Choice C, 'Risk-taking,' is incorrect as the nurse's actions aimed to minimize risks rather than taking them. Choice D, 'Creativity,' is not the best fit as the nurse's actions focused on following established protocols and ensuring patient safety rather than thinking innovatively.
A nurse manager is preparing to review practice guidelines with a group of newly licensed nurses. Which of the following interventions should the nurse include that is within the RN scope of practice?
- A. Insert an implanted port
- B. Close a laceration with sutures
- C. Place an endotracheal tube
- D. Initiate an enteral feeding through a gastrostomy tube
Correct Answer: D
Rationale: The correct answer is D: Initiate an enteral feeding through a gastrostomy tube. It is within the RN scope of practice for nurses to initiate enteral feedings through nasoenteric, gastrostomy, and jejunostomy tubes. Options A, B, and C involve procedures that typically fall within the scope of other healthcare professionals. Inserting an implanted port is often performed by specialized nurses or physicians, closing a laceration with sutures is usually done by healthcare providers with specific training in wound care, and placing an endotracheal tube is a procedure commonly carried out by anesthesiologists or respiratory therapists.
Postoperatively, signs of hemorrhagic shock are observed. The nurse notifies the surgeon, who instructs to continue monitoring vitals every 15 minutes and report back in one hour. What should the nurse do next?
- A. Notify the nurse manager
- B. Continue monitoring as instructed
- C. Administer IV fluids as per protocol
- D. Prepare for immediate transfer to the ICU
Correct Answer: B
Rationale: The correct answer is to continue monitoring the patient as instructed. This is crucial to assess the patient's condition and response to initial interventions. Administering IV fluids or preparing for transfer to the ICU should only be done based on further assessment or explicit orders from the healthcare provider. Notifying the nurse manager, as suggested in choice A, without further assessment or intervention could delay immediate patient care and management.
When is a depressed client at highest risk for attempting suicide?
- A. Immediately after admission, during one-to-one observation
- B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
- C. Following an angry outburst with family
- D. When the client is removed from the security room
Correct Answer: B
Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.
What action should the nurse take if she observes an unlicensed assistive personnel (UAP) soaking a client's foot in a basin of warm water placed on the bed during a total bed bath for a confused and lethargic client?
- A. Remove the basin of water from the client's bed immediately
- B. Remind the UAP to dry between the client's toes completely
- C. Advise the UAP that this procedure may damage the skin
- D. Add skin cream to the basin of water while the foot is soaking
Correct Answer: A
Rationale: The correct action for the nurse to take is to remove the basin of water from the client's bed immediately. Soaking a client's foot in a basin of water placed on the bed can lead to spills, create infection risks, and is not a safe practice. It is essential to prioritize the safety and well-being of the client by ensuring a safe environment during care procedures. Choices B, C, and D are incorrect as they do not address the immediate risk associated with the situation. Reminding the UAP to dry between the client's toes, advising about potential skin damage, or adding skin cream do not mitigate the immediate hazards of having a basin of water on the bed.