Nokea
A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
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A nurse is admitting an older adult client who was transferring from another facility. The nurse notes pressure ulcers on the clients Coccyx and abrasions around both wrists which of the following actions should the nurse take to address suspicion of elder abuse?
Which actions should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance.
- C. Report the findings to the appropriate authorities, following facility protocol.
- D. Take photographs of the injuries if permitted, as part of the documentation process.
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment.
Correct Answer: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion.
Which of the following actions should the nurse plan to take?
- A. Keep calcium gluconate at the client's bedside
- B. Monitor blood pressure every 2 hr.
- C. Protect IV bag from exposure to light.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct answer is C: Protect IV bag from exposure to light. This is important because certain medications in IV bags can degrade when exposed to light, leading to reduced efficacy or potential harm to the patient. Keeping the IV bag protected helps maintain the integrity of the medication.
Choice A is incorrect because calcium gluconate should be stored properly but doesn't necessarily need to be kept at the bedside at all times.
Choice B is incorrect as monitoring blood pressure every 2 hours may not be necessary for all patients and is not specific to the scenario given.
Choice D is incorrect as attaching an inline filter to the IV tubing may be necessary in certain situations but is not the most relevant action based on the information provided.
History and Physical
6-year-old child
Vomited 3 times in the past 24 hr
Irritable behavior for the past 24 hr
Respiratory infection started 3 days ago
Brudzinski's and Kernig's signs positive
Nurse is planning care for a child during admission to the facility. Which action should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: Positive Brudzinski's and Kernig's signs indicate meningitis, making seizure precautions the priority to prevent complications.
A charge nurse is concerned about a recent increase in facility-acquired catheter infections.
Which action should the nurse take?
- A. Identify possible precipitating factors related to the infection
- B. Reinforce proper hand hygiene practices among staff.
- C. Implement a protocol for timely removal of unnecessary catheters.
- D. Provide staff education on aseptic catheter insertion techniques.
- E. Conduct regular audits on catheter care compliance.
Correct Answer: E
Rationale: The correct action for the nurse to take is E: Conduct regular audits on catheter care compliance. Audits help monitor adherence to catheter care protocols, identify areas needing improvement, and ensure staff follow best practices consistently. This action promotes quality care, reduces infection risks, and enhances patient safety. Choices A, B, C, and D are important but do not directly address ongoing monitoring and assessment of compliance like regular audits do. Conducting audits is a proactive approach to continuously evaluate and improve catheter care practices, making it the most appropriate action in this scenario.
A nurse is providing care for a client who has esophageal cancer and has received radiation therapy.
Which of the following findings should the nurse identify as the priority?
- A. Xerostomia
- B. Client reports a pain level of 6 on a scale from 0 to 10
- C. Excoriation of the skin on the neck and chest
- D. Dysphagia
Correct Answer: D
Rationale: The correct answer is D: Dysphagia. Dysphagia poses the highest risk of aspiration, malnutrition, and dehydration. Priority is given to life-threatening or potentially life-threatening issues. Xerostomia (A) is uncomfortable but not immediately life-threatening. Pain level (B) can be managed with medication. Excoriation of the skin (C) can be treated topically.