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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. The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?
- A. Ask the patient�s family to participate in the diabetes education program.
- B. Assess the patient�s perception of what it means to have diabetes mellitus.
- C. Demonstrate how to check glucose using capillary blood glucose monitoring.
- D. Discuss the need for the patient to actively participate in diabetes management.
Correct answer: B
Rationale:
3. Attending a continuing education class on advanced technology in health care is interpreted as which of the following by the nurse manager?
- A. Only important for nurse managers
- B. Not important
- C. A waste of time
- D. Essential to nursing care
Correct answer: D
Rationale: The correct answer is D: 'Essential to nursing care.' Advancements in technology play a crucial role in modern healthcare delivery. By attending a class on advanced technology, the staff nurse can enhance their skills and knowledge, ultimately benefiting nursing care. Choices A, B, and C are incorrect because advanced technology is not exclusive to nurse managers, is important for improving patient care, and is not a waste of time as it helps nurses stay updated with the latest advancements.
4. A nurse is considering employment at a long-term care facility that has a functional nursing delivery system. Knowing this, the nurse could expect that:
- A. Each RN would coordinate care for a group of clients.
- B. One RN would pass meds for all clients on a unit.
- C. Each RN would deliver total care to an assigned group of clients.
- D. One RN, one LPN, and one unlicensed assistive personnel would share responsibility for a group of clients.
Correct answer: B
Rationale: In a functional nursing delivery system, tasks are divided among the staff based on their roles. One of these roles is medication administration, where one RN may pass medications for all clients on a unit. Option A is incorrect because coordinating care for a group of clients is more aligned with team nursing. Option C is incorrect as it describes total care nursing, not functional nursing. Option D is incorrect as it reflects team nursing with a mix of different roles sharing responsibility.
5. The staff nurse is experiencing what type of conflict when the babysitter calls to cancel on the day of an important committee meeting?
- A. Intergroup conflict
- B. Perceived conflict
- C. Role conflict
- D. Structural conflict
Correct answer: C
Rationale: The correct answer is C: Role conflict. Role conflict arises when one has conflicting responsibilities or obligations, such as being scheduled to work while also needing to care for children. In this scenario, the staff nurse faces a conflict between their role as a parent needing childcare and their role as a professional scheduled to present at a committee meeting. Intergroup conflict (A) involves disputes between different groups, not conflicting roles within an individual. Structural conflict (D) stems from issues within the organizational structure, not conflicting responsibilities. Perceived conflict (B) refers to misunderstandings or misinterpretations between parties, not conflicting roles.
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