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1. A nurse is completing an admission assessment for a client who reports vomiting and diarrhea for the past 3 days. Which of the following findings should the nurse expect?
- A. Blood pressure 144/82 mm Hg
- B. Urine specific gravity 1.03
- C. Neck vein distention
- D. Urine specific gravity 1.01
Correct answer: A
Rationale: In a client experiencing vomiting and diarrhea, the nurse should expect findings such as dehydration, which can lead to hypovolemia and subsequent increased heart rate and decreased blood pressure. A blood pressure of 144/82 mm Hg is indicative of possible dehydration in this client. Urine specific gravity is typically increased in dehydrated individuals, so choices B and D are incorrect. Neck vein distention is not a typical finding associated with vomiting and diarrhea; therefore, choice C is also incorrect.
2. Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse�s assessment of the patient?
- A. Bedtime glucose of 140 mg/dL
- B. Noon blood glucose of 52 mg/dL
- C. Fasting blood glucose of 130 mg/dL
- D. 2-hr postprandial glucose of 220 mg/dL
Correct answer: B
Rationale:
3. Which of the following is an example of a sentinel event in healthcare?
- A. A patient falling in the hospital without injury
- B. A near-miss medication error
- C. An unexpected patient death unrelated to the natural course of illness
- D. A patient developing an infection during a hospital stay
Correct answer: C
Rationale: The correct answer is C. A sentinel event in healthcare is an unexpected patient death unrelated to the natural course of illness. These events are serious occurrences that warrant immediate investigation and response to prevent their recurrence and ensure patient safety. Choices A, B, and D do not fit the definition of a sentinel event. While choices A, B, and D are serious incidents, they do not involve an unexpected patient death unrelated to the natural course of illness, which is the defining characteristic of a sentinel event.
4. What are the key elements essential to the implementation of case management? (Select all that apply.)
- A. Collaborative practice teams
- B. Established critical pathways
- C. Quality management system
- D. All of the above
Correct answer: D
Rationale: The correct answer is D, 'All of the above.' Established critical pathways, collaborative practice teams, and quality management systems are indeed key elements essential to the implementation of case management. Collaborative practice teams allow for multidisciplinary collaboration, established critical pathways help guide patient care, and a quality management system ensures that care provided meets established standards. Choice A, collaborative practice teams, is correct as they are fundamental for effective case management, involving various professionals working together. Choice B, established critical pathways, is also correct as they provide a structured approach to managing patient care. Choice C, quality management system, is correct as it ensures that care is delivered at high standards and continuously monitored for improvement. Therefore, all these elements are crucial for successful case management implementation.
5. When lifting a bedside cabinet to move it closer to a client, what action should the nurse take to prevent self-injury?
- A. Keep the feet close together.
- B. Use the back muscles for lifting.
- C. Stand close to the cabinet when lifting it.
- D. Bend at the waist.
Correct answer: A
Rationale: The correct answer is A: 'Keep the feet close together.' When lifting a heavy object such as a bedside cabinet, it is essential to maintain a wide base of support by keeping the feet close together. This provides better stability and reduces the risk of injury. Choice B is incorrect because using the back muscles for lifting can lead to back strain and injury; it is recommended to use the legs instead. Choice C is incorrect as standing close to the cabinet may cause the nurse to lose balance and strain the back. Choice D is incorrect because bending at the waist increases the risk of back injury. Therefore, the safest and most appropriate action is to keep the feet close together to ensure stability and prevent self-injury.
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