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1. The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first?
- A. Teach the patient about administering regular insulin.
- B. Schedule the patient for a fasting blood glucose level.
- C. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy.
- D. Provide teaching about an increased risk for fetal problems with gestational diabetes.
Correct answer: B
Rationale: The correct answer is B. Given the family history of diabetes, the initial action the nurse should take is to schedule the patient for a fasting blood glucose level. This will help in assessing if the patient has developed gestational diabetes. Choice A is incorrect because teaching about administering regular insulin is premature without confirming the diagnosis. Choice C is incorrect as an oral glucose tolerance test is typically done earlier in pregnancy. Choice D is incorrect as discussing fetal problems related to gestational diabetes should come after a confirmed diagnosis.
2. A new nurse manager is attempting to solve a management issue by using one solution after another until she solves the problem. This would be known as what type of method?
- A. Decision making
- B. Trial and error
- C. Experimentation
- D. Analysis
Correct answer: B
Rationale: The correct answer is B. Trial and error is a method used by new managers to solve problems by trying different solutions until one is successful. In this scenario, the nurse manager is using a trial and error approach by attempting various solutions until the issue is resolved. Choices A, C, and D are incorrect because decision making involves making choices based on available information, experimentation involves testing hypotheses in a controlled setting, and analysis entails examining data and information to gain insights or draw conclusions, none of which directly reflect the iterative process of trial and error.
3. A nurse recognizes which of the following as a primary goal of nursing?
- A. Assist patients to achieve a peaceful death.
- B. Improve personal knowledge and skills to enhance patient outcomes.
- C. Advocate for quality of life over the quantity of life.
- D. Work to control costs to enhance patients' quality of life.
Correct answer: A
Rationale: The correct answer is A: 'Assist patients to achieve a peaceful death.' One of the primary goals of nursing is to help patients experience a comfortable and peaceful passing when faced with terminal illness or at the end of life. This involves providing holistic care, managing symptoms, and ensuring that patients are as comfortable and pain-free as possible. Choices B, C, and D are incorrect because while improving knowledge and skills, advocating for quality of life, and controlling costs are important aspects of nursing care, they are not the primary goal related to end-of-life care.
4. A healthcare professional is preparing to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the healthcare professional delegate?
- A. Confirming that a client's pain has decreased after receiving an analgesic
- B. Ambulating a client who is postoperative
- C. Inserting an indwelling urinary catheter for a client
- D. Demonstrating the use of an incentive spirometer to a client
Correct answer: A
Rationale: The correct answer is option A: 'Confirming that a client's pain has decreased after receiving an analgesic.' This task involves assessing the effectiveness of the medication, which can be delegated to the assistive personnel. Options B, C, and D involve skills that should be performed by licensed healthcare professionals due to their complexity and potential risks if not done correctly. Ambulating a postoperative client requires monitoring for signs of distress or complications, inserting a urinary catheter involves an invasive procedure with infection risks, and demonstrating the use of medical devices like an incentive spirometer requires specialized knowledge to ensure correct usage.
5. A client with frequent tonic-clonic seizures is being admitted. What action should the nurse add to the client's plan of care?
- A. Ensure blankets are placed on all four sides of the bed.
- B. Refrain from using restraints during seizure activity.
- C. Position the client laterally during seizure activity.
- D. Have a tongue depressor available at the client's bedside.
Correct answer: D
Rationale: The correct action the nurse should add to the client's plan of care is to have a tongue depressor available at the client's bedside. This is important during a seizure to prevent the client from biting their tongue. Placing the client laterally helps maintain a clear airway and prevents aspiration, making choice C a good practice during seizure activity. Using restraints during a seizure can cause injuries and should be avoided, making choice B incorrect. Wrapping blankets around all four sides of the bed is unnecessary for seizure management and does not contribute to the client's safety during a seizure, making choice A incorrect.
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