Nokea
Which of the following values should the nurse monitor closely while a client is on total parenteral nutrition?
- A. calcium
- B. magnesium
- C. glucose
- D. cholesterol
Correct Answer: C
Rationale: Glucose is monitored closely when a client is on total parenteral nutrition, due to high glucose concentration in the solutions. The other values are not monitored as closely.
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To provide optimal continuity of care, the nurse should do all of the following except:
- A. document current functional status.
- B. have the physician phone a report to the receiving facility.
- C. copy appropriate parts of the medical record for transport to the receiving facility.
- D. phone a report to the facility.
Correct Answer: B
Rationale: It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility to support continuity of care. Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A copy of select portions of the medical record (according to facility policy) is another form of communication and supports continuity. A physician might be asked to be involved if there are specific medical needs or orders that she believe are important, but is generally not involved.
While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lay on her stomach to promote muscle development
- B. Notify the physician because a developmental or neurological evaluation is indicated
- C. Document the findings as normal in the nurse's notes
- D. Explain to the parents that their child is likely to be mentally retarded
Correct Answer: B
Rationale: Persistent head lag at 6 months suggests developmental or neurological issues, warranting immediate physician referral for evaluation.
As a type of quality indicator, an example of a structure standard is:
- A. a written philosophy.
- B. a procedure for a straight catheterization.
- C. a protocol for treatment of a client with chest pain.
- D. the diagnostic work-up for a client with abdominal pain.
Correct Answer: A
Rationale: Structure standards define all the conditions needed to operate, direct, and control a system. They do not address client care but rather describe structure with regard to purpose, such as philosophy, objectives, goals, hours of operation, and management responsibility.
The LPN needs to delegate a task to the nurse aide who is new to the unit. Which of these is the best option for the nurse to choose in proceeding?
- A. Delegate the task to the nurse aide, confirm understanding, and follow up to ensure the task was safely/correctly done.
- B. Delegate the task to the nurse aide, watch them perform the task without them seeing you, and follow up to ensure the task was done safely/accurately.
- C. Delegate the task to the nurse aide, supervise if needed and check in after the task to see if help is needed.
- D. Delegate the task to the nurse aide, ensure understanding of the task, and supervise task being performed.
Correct Answer: A
Rationale: Delegation is transferring responsibility for a task but sharing its accountability. It is the delegator's responsibility to make sure the delegatee understands the task prior and to follow up after to make sure it was done correctly and safely.
The nurse uses prioritization to determine all the following except:
- A. time allotment for certain tasks.
- B. appropriate interventions.
- C. treatment procedures.
- D. the need for client education.
Correct Answer: C
Rationale: Treatment procedures are standards of care as defined by the facility or nursing unit. If a treatment is indicated, the nurse is obligated to follow the established procedure to be compliant with practice standards. Established priorities contribute to the determination of time management, appropriate interventions, and the need for client education as a potential intervention.