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1. A nurse is assessing a client's readiness to learn about insulin self-administration. Which of the following statements should the nurse identify as an indication that the client is ready to learn?
- A. "I can concentrate best in the morning."
- B. "It is difficult to read the instructions because my glasses are at home."
- C. "I'm wondering why I need to learn this."
- D. "You will have to talk to my partner about this."
Correct answer: D
Rationale: The correct answer is D, "You will have to talk to my partner about this." This response indicates that the client is willing to involve their partner in the learning process, showing readiness to take responsibility and engage in the education. Choices A, B, and C demonstrate potential barriers to learning: A indicates a preference for learning time but does not show active involvement, B focuses on external factors hindering learning, and C reflects a lack of understanding or motivation for the learning.
2. Which of the following best describes the role of a nurse case manager?
- A. To provide direct patient care
- B. To manage healthcare facilities
- C. To advocate for patient rights
- D. To coordinate long-term care services
Correct answer: D
Rationale: The correct answer is D: 'To coordinate long-term care services.' A nurse case manager's primary role is to coordinate and manage long-term care services for patients, ensuring continuity and quality of care. Choice A is incorrect because providing direct patient care is typically the responsibility of nurses, not nurse case managers. Choice B is incorrect as managing healthcare facilities is a role usually fulfilled by healthcare administrators. Choice C is incorrect as advocating for patient rights is important but not the primary role of a nurse case manager.
3. The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?
- A. Give the patient 4 to 6 oz more orange juice.
- B. Administer the PRN glucagon (Glucagon) 1 mg IM.
- C. Have the patient eat some peanut butter with crackers.
- D. Notify the healthcare provider about the hypoglycemia.
Correct answer: A
Rationale: The correct action for the nurse to take next is to give the patient 4 to 6 oz more orange juice. The patient's blood glucose has increased from 62 mg/dL to 67 mg/dL after consuming the initial 4 oz of orange juice, indicating that the treatment is effective. Providing additional orange juice will help further raise the blood glucose levels. Administering glucagon (Choice B) is not necessary as the patient's blood glucose is already rising. Having the patient eat peanut butter with crackers (Choice C) is a slower-acting option compared to orange juice. Notifying the healthcare provider about the hypoglycemia (Choice D) is not needed at this point since the patient's blood glucose is improving.
4. During a home safety assessment, a nurse is evaluating a client who is receiving supplemental oxygen. Which observation should the nurse identify as a proper safety protocol?
- A. The client has a weekly inspection checklist for oxygen equipment.
- B. The client stores an extra oxygen tank on its side under their bed.
- C. The client identifies the location of a fire extinguisher.
- D. The client uses a wool blanket on their bed.
Correct answer: A
Rationale: The correct answer is A because having a weekly inspection checklist for oxygen equipment ensures that the client can monitor the safety and functionality of the oxygen equipment regularly. This is crucial for maintaining a safe environment. Choice B is incorrect because storing an extra oxygen tank on its side under the bed can pose a safety hazard, as tanks should be stored upright. Choice C is a good safety practice, but it is not directly related to oxygen use. Choice D is incorrect because wool blankets are flammable and should not be used by clients receiving supplemental oxygen due to the increased risk of fire.
5. Staff are sometimes injured when a patient or visitor becomes agitated. If a staff member reports an injury, the following actions should take place: (EXCEPT)
- A. Notify security.
- B. Complete an incident report.
- C. Notify the nursing supervisor.
- D. Ensure that staff has been examined.
Correct answer: B
Rationale: When a staff member reports an injury resulting from an agitated patient or visitor, several actions should be taken. These actions include notifying security to ensure safety, notifying the nursing supervisor for appropriate follow-up, and ensuring that the injured staff member has been examined to assess the extent of the injury. Completing an incident report is not the correct action to exclude because documenting the incident is crucial for legal and healthcare purposes. Incident reports provide a detailed account of what occurred, which is essential for investigations, insurance claims, and improving safety protocols. Therefore, all other options are necessary steps to take when a staff member reports an injury, making completing an incident report the correct answer for exclusion.
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