Nursing Elites

1. A nurse is caring for a client who is postoperative and is exhibiting signs of hemorrhagic shock. The nurse notifies the surgeon, who tells the nurse to continue to measure the client's vital signs every 15 min and to report back in 1 hour. Which of the following actions should the nurse take next?

• A. Document the surgeon's instructions in the client's medical record.
• B. Complete an incident report.
• C. Consult the charge nurse.
• D. Notify the nursing manager.

Correct answer: D

Rationale: In this scenario, the nurse should notify the nursing manager next. The surgeon's instructions are related to the client's condition, and it is crucial to inform the nursing manager about the situation. Option A is incorrect because documenting the surgeon's instructions in the medical record is not the immediate next step. Option B is also incorrect as completing an incident report is not warranted in this situation. Option C is not the best choice as consulting the charge nurse may cause a delay in escalating the situation to higher management, which is necessary in cases of emergency like hemorrhagic shock.

2. After receiving change-of-shift report, which patient should the nurse assess first?

• A. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12%
• B. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL
• C. 40-year-old who is pregnant and has an oral glucose tolerance test result of 202 mg/dL
• D. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain

Correct answer: B

Rationale: The correct answer is B because the patient with a blood glucose level of 40 mg/dL (hypoglycemia) needs immediate attention. Hypoglycemia is an emergency situation that requires prompt intervention to prevent adverse effects such as seizures or loss of consciousness. Assessing and managing this patient first is crucial to prevent further deterioration. Choices A, C, and D do not present immediate life-threatening situations requiring urgent intervention like severe hypoglycemia does. While a high hemoglobin A1C level (choice A), an abnormal oral glucose tolerance test result (choice C), and acute abdominal pain (choice D) are important issues, they do not pose an immediate threat to the patient's life compared to severe hypoglycemia.

3. Which of the following is an example of a secondary prevention activity?

• A. Blood pressure screening
• B. Administering medications
• C. Developing a care plan
• D. Providing rehabilitation

Correct answer: A

Rationale: The correct answer is A, blood pressure screening. Secondary prevention aims to identify and treat conditions early to prevent their progression. Blood pressure screening helps in early detection of hypertension, allowing for timely intervention. Choices B, C, and D are not examples of secondary prevention activities. Administering medications (B) can be part of treatment after a condition is diagnosed, developing a care plan (C) is more related to organizing and coordinating care rather than prevention, and providing rehabilitation (D) focuses on recovery and improvement post-diagnosis rather than early detection and prevention.

4. In a multiple-car accident with multiple trauma clients being sent to an Emergency Department, which type of leadership would be most effective in this situation?

• A. Democratic
• B. Bureaucratic
• C. Laissez-faire
• D. Autocratic

Correct answer: D

Rationale: In a high-stress situation like a multiple-car accident with multiple trauma clients arriving at the Emergency Department, autocratic leadership is most effective. This type of leadership allows for clear direction and quick decision-making, crucial in managing emergencies. Democratic leadership may slow down the decision-making process due to the need for consensus. Bureaucratic leadership focuses on following established rules and procedures, which may not be flexible enough in an emergency. Laissez-faire leadership, characterized by a hands-off approach, is not suitable in urgent situations where immediate action is required.

5. What is the main purpose of a healthcare proxy?

• A. To manage financial affairs
• B. To make medical decisions on behalf of the patient
• C. To provide legal representation
• D. To oversee patient discharge planning

Correct answer: B

Rationale: The main purpose of a healthcare proxy is to make medical decisions on behalf of the patient when they are unable to do so. Choice A is incorrect as managing financial affairs is typically handled by a power of attorney for finances. Choice C is incorrect as a healthcare proxy is not meant to provide legal representation. Choice D is incorrect as overseeing patient discharge planning is a responsibility of healthcare providers, not a healthcare proxy.

Similar Questions