Nokea
A nurse is caring for a client who has an indwelling urinary catheter. Which of the following findings indicates that the catheter requires irrigation?
- A. Urine is positive for ketones
- B. Urine has an unusual odor
- C. Urine specific gravity is 1.035 (normal range: 1.010 to 1.025)
- D. Bladder scan shows 525 mL of urine
Correct Answer: A
Rationale: The correct answer is A because the presence of ketones in the urine may indicate dehydration or infection, which can lead to catheter obstruction. Irrigation may be needed to clear the catheter and prevent further complications. Choices B, C, and D are incorrect because an unusual odor, high specific gravity, and a significant amount of urine in the bladder do not necessarily indicate the need for catheter irrigation.
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Which of the following is an important aspect of note-taking?
- A. Not specific and behavior-oriented
- B. Forces the manager to deal with the problem
- C. Records only undesirable events
- D. Failure to give performance feedback
Correct Answer: B
Rationale: The correct answer is B because note-taking forces the manager to deal with the problem by documenting important information, actions, and decisions. This helps in tracking progress, identifying trends, and making informed decisions. It promotes accountability and ensures issues are addressed promptly.
A: Not specific and behavior-oriented - Incorrect. Note-taking should be specific and focus on behaviors to provide accurate and detailed information.
C: Records only undesirable events - Incorrect. Note-taking should capture both positive and negative events for a comprehensive view.
D: Failure to give performance feedback - Incorrect. Note-taking is a tool to provide feedback and track performance effectively.
A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam
- A. every 2 years
- B. as soon as possible
- C. when the patient is 39 years old
- D. within the first year after diagnosis
Correct Answer: B
Rationale: The correct answer is B (as soon as possible) because individuals with type 2 diabetes are at risk for diabetic retinopathy, a complication that can lead to vision loss. Early detection through a dilated eye exam allows for timely intervention to prevent or slow down progression. Choice A (every 2 years) may not be frequent enough for early detection. Choice C (when the patient is 39 years old) is not specific to the individual's diabetes diagnosis. Choice D (within the first year after diagnosis) is too delayed for optimal monitoring. Thus, scheduling a dilated eye exam as soon as possible is crucial for early detection and management of diabetic retinopathy.
A nurse manager is interested in solving a serious conflict that exists among the nursing staff. He uses a strategy that involves allowing the group to explore a number of solutions and come to a consensus on a solution. What strategy for conflict resolution has the manager used?
- A. Integrative decision-making
- B. Win-win
- C. Competing
- D. Confrontation
Correct Answer: A
Rationale: The correct answer is A: Integrative decision-making. This strategy involves allowing the group to explore multiple solutions and reach a consensus, fostering collaboration and mutual benefit. This approach promotes a win-win outcome and encourages open communication and respect among team members. It is effective for resolving conflicts as it focuses on finding a solution that satisfies the interests of all parties involved.
Choice B: Win-win is a similar concept to integrative decision-making but lacks the emphasis on exploring multiple solutions and reaching a consensus.
Choice C: Competing involves one party winning at the expense of the other, contrary to the collaborative nature of integrative decision-making.
Choice D: Confrontation is a direct and aggressive approach that does not promote collaboration or consensus-building like integrative decision-making does.
When seeking their first nursing job, what is the most important factor that nursing graduates look for?
- A. Location
- B. Money
- C. Orientation
- D. Vacation
Correct Answer: C
Rationale: The correct answer is C: Orientation. Nursing graduates prioritize orientation as the most important factor when seeking their first job because it sets the foundation for their transition into the role. A thorough orientation program provides essential training, support, and guidance, which are crucial for their success and confidence in their new position. Location (A) may be important for convenience, but orientation directly impacts their ability to perform their duties effectively. Money (B) and vacation (D) are important but typically take a back seat to factors that directly impact their ability to excel in their new role.
A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour. Which of the following actions should the nurse take next?
- A. Document the surgeon's instructions in the client's medical record.
- B. Complete an incident report.
- C. Consult the charge nurse.
- D. Notify the nursing manager.
Correct Answer: D
Rationale: The correct answer is D: Notify the nursing manager. The nurse should escalate the situation to the nursing manager because the surgeon's instructions may not be appropriate for a client in hemorrhagic shock. The nurse needs to advocate for the client's safety and ensure prompt and appropriate intervention. Consulting the charge nurse may not be sufficient, and documenting the instructions or completing an incident report does not address the immediate need for proper medical intervention.