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1. 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:
2. Which of the following conditions would be well suited to the use of a nursing critical pathway?
- A. Foreign object in the ear
- B. Fever of unknown origin
- C. Hip replacement surgery
- D. Bacterial infection acquired in a foreign country
Correct answer: C
Rationale: A critical pathway is designed to track a patient's progress through a specific timeline, including assessments, interventions, treatments, and outcomes. Hip replacement surgery is well suited for a nursing critical pathway because it has a defined timeline with specific interventions and treatments aimed at achieving optimal functioning. Choices A, B, and D do not typically follow a structured timeline with predetermined interventions and outcomes, making them less suitable for a critical pathway.
3. Which of the following best describes the concept of patient-centered care?
- A. Care that is directed solely by healthcare providers
- B. Care that involves coordination among multiple healthcare providers
- C. Care that prioritizes the patient's preferences, needs, and values
- D. Care that strictly adheres to the latest clinical guidelines
Correct answer: C
Rationale: Patient-centered care is a healthcare approach that places the patient at the center of decision-making, emphasizing their preferences, needs, and values. This approach ensures that care is tailored to individual patients, taking into account their unique circumstances and actively involving them in their own care. Choice A is incorrect because patient-centered care focuses on the patient's needs rather than being solely directed by healthcare providers. Choice B is incorrect as involving multiple healthcare providers doesn't necessarily mean care is patient-centered; instead, it's about tailoring care to the patient's individual needs. Choice D is also incorrect as patient-centered care goes beyond just following clinical guidelines to encompass individual patient preferences and values.
4. A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain?
- A. Is your pain constant or intermittent?
- B. What would you rate your pain on a scale of 0 to 10?
- C. Does the pain radiate?
- D. Is your pain sharp or dull?
Correct answer: D
Rationale: When assessing the quality of pain, asking if the pain is sharp or dull helps the nurse understand the nature of the pain. Sharp pain is often associated with acute conditions like nerve irritation or injury, while dull pain may indicate a more chronic issue like inflammation or tissue damage. Choices A, B, and C focus on different aspects of pain assessment but do not specifically address the quality of pain, making them less relevant in this context.
5. 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.
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