Nokea
Which preventive measure can be employed to decrease the risk of compartment syndrome?
- A. The administration of a potassium-sparing diuretic for heart failure
- B. A bivalve cast for a skeletal fracture
- C. A cerebral diuretic to decrease intracranial pressure after a head injury
- D. A chest tube to restore normal intrathoracic pressure after a pneumothorax
Correct Answer: B
Rationale: The correct answer is B. A bivalve cast can help decrease the risk of compartment syndrome by providing space for swelling, thus preventing the build-up of pressure within the muscles. Choices A, C, and D are incorrect because they are not directly related to preventing compartment syndrome. Choice A is more focused on managing heart failure, choice C on reducing intracranial pressure, and choice D on restoring intrathoracic pressure after a pneumothorax, which are not relevant to preventing compartment syndrome.
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A nurse is caring for a client who reports acute pain but refuses IM medication. The nurse distracts the client and quickly administers the injection. This illustrates which of the following?
- A. Assault
- B. False imprisonment
- C. Battery
- D. Libel
Correct Answer: C
Rationale: The correct answer is C, 'Battery.' Administering the injection without the client's consent constitutes battery. Assault involves the threat of harm, not the actual act. False imprisonment is restraining a client against their will, which does not apply here. Libel refers to a false written statement, which is not relevant in this scenario.
A nurse is supervising an assistive personnel (AP) who is feeding a client who has dysphagia. Which of the following actions by the AP should the nurse identify as correct technique?
- A. Elevating the head of the client's bed to 30 degrees during mealtime
- B. Withholding fluids until the end of the meal
- C. Providing a 10-minute rest period prior to meals
- D. Instructing the client to place her chin toward her chest when swallowing
Correct Answer: D
Rationale: The correct technique for a client with dysphagia is to instruct them to place their chin toward their chest when swallowing. This action helps to close off the airway during swallowing, reducing the risk of aspiration. Elevating the head of the client's bed to 30 degrees during mealtime helps prevent aspiration, but this is not the responsibility of the AP. Withholding fluids until the end of the meal can lead to dehydration and is not a recommended practice. Providing a 10-minute rest period prior to meals is not specifically related to improving swallowing safety for clients with dysphagia.
A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?
- A. Transport the client to the operating room without verifying informed consent
- B. Ask the anesthesiologist to sign the consent
- C. Obtain telephone consent from the facility administrator before the surgery
- D. Delay the surgery until the nurse can obtain informed consent
Correct Answer: A
Rationale: In emergency situations where a client is unconscious and requires immediate surgery, implied consent applies. Implied consent allows healthcare providers, including nurses, to proceed with necessary treatment or surgery without formally verifying informed consent. Choice A is correct because the priority in this scenario is to ensure the client receives timely medical intervention to address life-threatening conditions. Choices B, C, and D are incorrect because in emergencies, waiting to obtain formal consent can delay critical treatment, risking the client's health and well-being.
Which of the following is expected to be most likely true in the near future?
- A. Quality improvement projects will decline due to cost-cutting measures.
- B. Alternative and complementary approaches will gain acceptance in medical practice.
- C. Care will primarily shift away from the hospital setting.
- D. Increased focus on care transitions will involve nursing.
Correct Answer: D
Rationale: In the near future, there will be an increased focus on care transitions involving nursing. This means that nurses will play a crucial role in preparing patients for transitions between different care settings, ensuring continuity and quality of care. Choice A is incorrect because quality improvement projects are essential and are not expected to decline. Choice B is incorrect as alternative and complementary approaches are increasingly being integrated into medical practice. Choice C is incorrect as there is a growing trend towards providing care in community settings and homes, moving away from primarily hospital-based care.
A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
- A. The client with renal failure
- B. The client who is taking diuretics
- C. The client with hyperaldosteronism
- D. The client who is taking corticosteroids
Correct Answer: B
Rationale: The correct answer is B. Clients taking diuretics are at risk for hyponatremia due to excessive sodium loss. In this scenario, a sodium level of 130 mEq/L indicates hyponatremia, which is commonly associated with diuretic use. Options A, C, and D are not the highest risk factors for developing low sodium levels in this context. Renal failure, hyperaldosteronism, and corticosteroid use are not directly linked to sodium loss as seen with diuretics.