Nokea
In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:
- A. diabetic signs and symptoms.
- B. nutritional status.
- C. bleeding problems.
- D. availability of insulin.
Correct Answer: C
Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.
You may also like to solve these questions
When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?
- A. Bathing a client who is confused and requires assistance with a shower
- B. Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
- C. Assisting a client requiring a bed bath and frequent ambulation with a cane
- D. Transporting a client who must be accompanied to physical therapy twice during the shift
Correct Answer: B
Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.
Which of the following clients would be most appropriate for an LPN to assign to a nursing assistant?
- A. an 18-year-old client with a femur fracture who is just returning to the floor from the recovery unit
- B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
- C. a 35-year-old client who is suffering from an acute asthma attack
- D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection
Correct Answer: D
Rationale: Collecting sputum samples on stable clients is within the scope of practice for an LPN. This task does not require immediate intervention or assessment by an RN or medical provider. An RN should perform the initial assessment on any client immediately post-op as it requires a higher level of assessment and monitoring. A client suffering from an acute asthma attack should be attended to by an RN or medical provider due to the potential severity and need for prompt intervention. Assigning a medically stable client who needs help ambulating to a nursing assistant is appropriate as it falls within their scope of practice and allows the LPN to focus on tasks that require their expertise.
Which situation is an example of the use of evidence-based practice in the delivery of client care?
- A. Encouraging a client who has had a stroke to consume thickened liquids and soft foods
- B. Picking up a dislodged radiation implant with long-handled forceps and placing it in a lead container to minimize radiation exposure
- C. Pouring 1 to 2 mL of sterile solution that will be used for wound cleansing into a plastic-lined waste receptacle before pouring the solution into a sterile basin
- D. Blowing on a fingerstick site to dry it after cleaning the site with an alcohol swab
Correct Answer: C
Rationale: Evidence-based practice is an approach that integrates client preferences, clinical expertise, and the best research evidence to deliver quality care. Pouring sterile solution into a plastic-lined waste receptacle before using it for wound cleansing reflects evidence-based practice by preventing the entrance of harmful bacteria into the wound. Option A is incorrect because encouraging a stroke client to consume thickened liquids and soft foods is appropriate, not thin liquids and foods that pose a choking risk. Option B is incorrect as picking up a radiation implant with long-handled forceps to minimize radiation exposure is a safety measure, not evidence-based practice. Option D is incorrect because blowing on a fingerstick site after cleaning can recontaminate the site, which goes against best practices in infection control.
Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:
- A. Outbreak of Asian flu.
- B. Chemical exposure.
- C. Bacterial pneumonia.
- D. Allergic reaction.
Correct Answer: B
Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure. In this scenario, considering the sudden onset of symptoms in multiple passengers on an airliner, the symptoms are more indicative of a chemical exposure rather than Asian flu, bacterial pneumonia, or an allergic reaction. Asian flu, bacterial pneumonia, and allergic reactions do not typically manifest in a way that would affect a group of individuals simultaneously. Therefore, the correct diagnosis in this case is likely to be a chemical exposure.
Once the nurse has made initial rounds and checked all of the assigned clients, which client should be cared for first?
- A. A client who is scheduled for surgery at 1 p.m.
- B. A client in skeletal traction who has just received pain medication
- C. A client scheduled for physical therapy at 11 a.m.
- D. A client who is able to perform activities of daily living independently
Correct Answer: A
Rationale: The priority should be given to the client who is scheduled for surgery at 1 p.m. Preparing a client for surgery involves various tasks such as physical and emotional preparation, following healthcare provider instructions, and potential last-minute changes in the surgical schedule. It is crucial to ensure the client is adequately prepared. Providing care to a client who just received pain medication can wait until the medication takes effect. Clients who are independent in performing daily activities and those scheduled for physical therapy later in the morning are not as high a priority as preparing a client for an upcoming surgery. Therefore, the client scheduled for surgery should be cared for first to ensure all necessary preparations are completed.