Nokea
Which of the following actions should the nurse take?
- A. Limit oral feedings to 30 min in length.
- B. Check the infant's oxygen saturation every 6 hr
- C. Place the infant in the prone position for naps
- D. Weigh the infant every other day.
Correct Answer: A
Rationale: Limiting feeding durations conserves energy for infants with heart failure.
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Which of the following responses should the nurse make?
- A. It is always difficult caring for someone who is terminally ill.
- B. You should consider taking a sleeping pill before bed each night.
- C. I can give you information about respite care if you are interested.
- D. I am sure you're doing a great job taking care of your mother.
Correct Answer: C
Rationale: Respite care provides temporary relief for caregivers, which can improve their well-being.
A charge, nurse is teaching new staff members about factors that increase a client's risk to become violent: Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. A history of being in prison
- B. Male gender
- C. Experiencing delusions
- D. Previous violent behavior
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to engage in violent acts again. Choice A (A history of being in prison) is not as strong of a predictor as it does not specifically address violent behavior. Choice B (Male gender) is a generalization and not always indicative of violent behavior. Choice C (Experiencing delusions) may increase the risk of violence but does not directly predict future violent behavior as strongly as previous violent actions do.
A nurse is caring for a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?
- A. Polyuria
- B. Hypotension
- C. Weight loss
- D. Hematuria
Correct Answer: D
Rationale: The correct answer is D: Hematuria. In acute glomerulonephritis, there is inflammation of the glomeruli in the kidneys leading to blood in the urine. This is known as hematuria. Polyuria (choice A) is not typically seen in this condition as the kidneys are not able to effectively filter urine. Hypotension (choice B) is unlikely as fluid retention and hypertension are more common due to decreased kidney function. Weight loss (choice C) is not a common finding as the condition often leads to fluid retention. Therefore, hematuria is the most expected finding in acute glomerulonephritis.
Which of the following guidelines should the nurse manager include?
- A. Remove the client's restraint every 4 hr
- B. Document the client's condition every 15 min.
- C. Request a PRN restraint prescription for clients who are aggressive.
- D. Attach the restraint to the bed's side rails.
Correct Answer: B
Rationale: The correct answer is B: Document the client's condition every 15 min. This guideline is crucial to monitor the client's well-being, detect any changes promptly, and ensure the effectiveness of the restraint. Removing the restraint every 4 hours (choice A) can compromise the client's safety and defeat the purpose of using restraints. Requesting a PRN restraint prescription for aggressive clients (choice C) may lead to overuse of restraints without proper assessment. Attaching restraints to the bed's side rails (choice D) can increase the risk of injury and is not recommended. Regular documentation is essential in ensuring the client's safety and well-being.
A nurse is caring for a client who is experiencing expressive aphasia and right hemiparesis following a stroke. Which of the following actions by the nurse best promotes communication among staff caring for the client?
- A. Posting swallowing precautions at the head of the client’s bed
- B. Noting changes in the treatment plan in the client's medical record
- C. Recording the client's progress in the nurses’ notes
- D. Having interdisciplinary team meetings for the client on a regular basis.
Correct Answer: D
Rationale: Rationale for the Correct Answer (D): Having interdisciplinary team meetings for the client on a regular basis is the best action to promote communication among staff caring for the client. This approach ensures that all healthcare team members are regularly updated on the client's condition, progress, and treatment plan. It allows for collaborative decision-making and coordination of care, leading to a holistic and effective approach to managing the client's needs. Additionally, it provides an opportunity for staff to discuss any challenges, share insights, and adjust interventions as needed to optimize the client's outcomes.
Summary of Incorrect Choices:
A: Posting swallowing precautions at the head of the client's bed is important for safety but does not directly promote communication among staff.
B: Noting changes in the treatment plan in the client's medical record is essential for documentation but may not facilitate real-time communication among staff members.
C: Recording the client's progress in the nurses' notes is necessary for tracking the client's status but does not ensure comprehensive communication among all team