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While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. The nurse should:
- A. make the charge nurse on the unit aware of the situation so that he or she can take the necessary steps to maintain the confidentiality of the information being reported.
- B. disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
- C. return to his or her own unit and not disclose that confidential information has been overheard.
- D. ignore the situation.
Correct Answer: A
Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation so that the information can be communicated in an appropriate way in privacy.
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Which of the following is not true of clinical pathways?
- A. They need to be updated daily.
- B. They show how the client is expected to respond to their diagnosis.
- C. The goal is improvement or discharge from the facility.
- D. They are evidence based.
Correct Answer: A
Rationale: Clinical pathways may be daily or weekly, so they may not need to be updated every day.
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?
- A. emotional support to help the family deal with feelings of guilt about the infant's condition
- B. administration of MICRhoGam to the woman within 72 hours of delivery
- C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
- D. lab analysis of maternal Direct Coombs' test
Correct Answer: A
Rationale: Sensitization means the mother has antibodies against Rh-positive blood, risking hemolytic disease in the fetus. Emotional support is critical to address guilt and concerns about the infant's condition.
A preschooler has successfully completed the test item 'counts 5 blocks' on the Denver II test. This pass is evidence of which of the following developmental concepts?
- A. centration
- B. causality
- C. nonreversibility
- D. conservation
Correct Answer: D
Rationale: Counting five blocks demonstrates conservation, the understanding that quantity remains constant despite changes in arrangement or appearance.
Which of these is true regarding advance directives?
- A. They must be reviewed and re-signed every 10 years in order to remain valid.
- B. An advanced directive is legally valid in every state, no matter which state it was created in.
- C. A physician must determine when a client is unable to make medical decisions for himself.
- D. They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.
Correct Answer: D
Rationale: If summoned, EMTs are legally obligated to provide emergency care to a client, regardless of advance directive status, unless the directive is signed by a doctor. If the client is brought to the hospital, physicians will evaluate the client and implement the advance directive, if necessary. Two physicians, not one, are needed to determine if a client is unable to make decisions for himself/herself. Advance directives do not expire and remain in effect until they are changed. Some states do not honor advance directives created in other states, so if a client moves, he/she should check with his/her new state policies on this topic.
Which is the correct order regarding the hierarchy of members of the nursing team from least authority to highest authority?A.staff nurse ,B.nurse manager,C.LPN ,D.charge nurse
- A. A) C, D, A, B
- B. B) A, C, B, D
- C. C) C, A, D, B
- D. D) C, A, B, D
Correct Answer: C
Rationale: Nurse managers oversee charge nurses who oversee staff nurses who oversee LPNs.