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Which of these clients would the nurse recommend keeping in the hospital during an internal disaster at that facility?
- A. An adolescent diagnosed with sepsis 7 days ago and whose vital signs are maintained within low normal limits.
- B. A middle-aged woman known to have had an uncomplicated myocardial infarction 4 days ago
- C. An elderly man admitted 2 days ago with an acute exacerbation of ulcerative colitis
- D. A young adult in the second day of treatment for an overdose of acetaminophen
Correct Answer: D
Rationale: A young adult in the second day of treatment for an overdose of acetaminophen. An overdose of Tylenol requires close observation for 3 to 4 days as well as Mucomyst PO during that time. A strong risk of liver failure exists immediately following Tylenol overdose.
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Pressure is being exerted to the client's foot ulcer from the bottom bed guard, and the client needs to be pulled up in bed. The client weighs 130 lb. Which action by the nurse is best when no one is available to assist the nurse?
- A. Wait until sufficient help is available to pull up and reposition the client in bed
- B. Place pillows over the bed guard and elevate both of the client's legs on the pillows
- C. Place the bed in Trendelenburg position to relieve the pressure and then wait for help
- D. Use a slight Trendelenburg position, have the client lift the heels, and pull the client up in bed
Correct Answer: D
Rationale: Using a slight Trendelenburg position leverages gravity to assist in moving a lightweight client safely, while lifting the heels prevents friction injury. Waiting for help (A) delays relief, pillows (B) risk sliding, and full Trendelenburg (C) may compromise respiration.
A risk management program within a hospital is responsible for all of the following except:
- A. identifying risks.
- B. controlling financial loss due to malpractice claims.
- C. making sure that staff follow their job descriptions.
- D. analyzing risks and trends to guide further interventions or programs.
Correct Answer: C
Rationale: Risk management is an organizationwide program to identify risks and control incidents and legal liability. It does not have any direct supervisory or management responsibility for staff.
The nurse has been teaching a client with congestive heart failure about proper nutrition. Which of these lunch selections indicates the client has learned about sodium restriction?
- A. Cheese sandwich with a glass of 2% milk
- B. Sliced turkey sandwich and canned pineapple
- C. Cheeseburger and baked potato
- D. Mushroom pizza and ice cream
Correct Answer: B
Rationale: Sliced turkey sandwich and canned pineapple. Sliced turkey sandwich is appropriate since it is not a highly processed food and canned fruits are low in sodium. All of the other choices contain one or more high-sodium foods.
A client with a history of a splenectomy has a left upper quadrant mass and is scheduled for a splenectomy. The nurse knows that this client is most at risk for what complication?
- A. Respiratory complications
- B. Bleeding tendencies
- C. Peritonitis
- D. Intestinal obstruction
Correct Answer: B
Rationale: The spleen plays a role in filtering blood and producing immune cells. A history of splenectomy increases the risk of bleeding due to decreased platelet function and impaired immune response.
A client with a diagnosis of bipolar disorder has been referred to a local boarding home for consideration for placement. The social worker telephoned the hospital unit for information about the client's mental status and adjustment. The appropriate response of the nurse should be which of these statements?
- A. I am sorry. Referral information can only be provided by the client's providers
- B. I can never give any information out by telephone. How do I know who you are?
- C. Since this is a referral, I can give you this information
- D. I need to get the client's written consent before I release any information to you
Correct Answer: D
Rationale: In order to release information about a client there must be a signed consent form with designation of to whom information can be given, and what information can be shared.