Nokea
Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct Answer: D
Rationale: The correct answer is D because an oxygen saturation of 96% on room air indicates adequate oxygenation, suggesting the client is stable and can be discharged home. A: Low urine output may indicate dehydration or kidney issues, requiring further monitoring. B: A fever in an infant warrants evaluation for infection, not ready for discharge. C: Recent transition from IV TPN to full liquids may require ongoing monitoring for tolerance and nutritional status.
You may also like to solve these questions
The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct Answer: A
Rationale: The correct answer is A: Unequal leg length. In developmental dysplasia of the hip, there is abnormal development of the hip joint. This can lead to unequal leg lengths due to hip instability and dislocation. Limited adduction may be present due to hip joint abnormalities. Diminished femoral pulses are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds are usually present in healthy infants.
A nurse is using active listening as a form of therapeutic communication when:
- A. She uses humor to put the client at ease in a situation
- B. She restates what the client said in slightly different words
- C. She uses eye contact and maintains an open stance while the client is talking
- D. She provides personal information to show the client she can relate to him
Correct Answer: C
Rationale: The correct answer is C because using eye contact and maintaining an open stance while the client is talking demonstrates active listening. Eye contact shows attentiveness and respect, while an open stance conveys empathy and receptiveness. This non-verbal communication encourages the client to feel heard and understood, fostering a therapeutic relationship.
Choice A is incorrect because using humor may not always align with the client's feelings or be perceived as appropriate. Choice B is incorrect as restating what the client said is a form of paraphrasing, not active listening. Choice D is incorrect because providing personal information can shift the focus away from the client's needs and may breach professional boundaries.
Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?
- A. Collect and organize documents for the client's medical record
- B. Prepare the client's identification bracelet
- C. Identify pertinent health history data and current needs and limitations
- D. Gather the client's valuables and secure them in a locked container
Correct Answer: C
Rationale: The correct answer is C because identifying pertinent health history data and current needs and limitations is crucial in developing an individualized care plan for the stroke patient. This data helps determine the appropriate interventions and therapies needed for the client's recovery. Collecting and organizing documents (choice A) can be important but not the primary action. Preparing an identification bracelet (choice B) and gathering valuables (choice D) are important tasks but not the immediate priority upon admission.
A nurse is caring for a dying client whose family wants to be with him in the operating suite. The surgeon, however, does not allow families to be present during surgery. The nurse recognizes this as an ethical dilemma. What is the initial step of the nurse when managing this situation?
- A. Contact the physician to amend the order for the client
- B. Document an account of the situation to ensure adequate coverage of details
- C. Consult with the medical ethics committee to determine a safe and workable solution
- D. Speak with the chief nursing officer to change the policy governing this situation
Correct Answer: A
Rationale: The correct initial step is to choose option A: Contact the physician to amend the order for the client. This is the most appropriate action because the conflict arises from the surgeon's policy, which can potentially be changed with physician involvement. By discussing the situation with the physician, the nurse can advocate for the family's wishes and potentially negotiate a compromise. This step prioritizes the client's and family's needs while also respecting the surgeon's authority. Options B, C, and D are not the initial steps because they involve escalating the situation before attempting direct communication with the physician, which can be seen as bypassing the appropriate chain of command.
A client is seen in the emergency room as a victim of suspected domestic violence. The nurse's aide brings the client to a center curtained area, gives her a gown to change into, and asks her to wait for the nurse. What is the most appropriate action of the nurse upon arrival?
- A. Ask the client to undress to assess for injuries
- B. Take the client into a private room
- C. Notify the police to file a report
- D. Notify the house supervisor to keep security on alert
Correct Answer: B
Rationale: The correct answer is B: Take the client into a private room. This is the most appropriate action because it ensures the client's privacy and confidentiality, which is crucial in cases of suspected domestic violence. By placing the client in a private room, the nurse can establish a safe and secure environment for the client to disclose sensitive information and receive proper care. This approach also helps to build trust with the client and allows for a thorough assessment of injuries without compromising the client's dignity.
Choice A is incorrect because asking the client to undress immediately may further traumatize the client and violate her privacy. Choice C is not the nurse's immediate responsibility; the priority is to ensure the client's safety and well-being. Choice D is also not the most appropriate action as it does not directly address the client's immediate needs.