Nursing Elites

1. While taking care of a client, the nurse thinks that physical therapy in the hospital might be beneficial to their condition. The following is the ideal referral process EXCEPT?

• A. Transport the client to the physical therapy room for treatment after receiving an official referral.
• B. Provide the physical therapist with the client's medical record after the referral.
• C. Contact the client's primary care provider to suggest a physical therapy referral.
• D. Request the client to self-refer to the physical therapist.

Correct answer: D

Rationale: The ideal referral process for a client to receive physical therapy in the hospital starts with the nurse contacting the client's primary care provider to discuss and suggest a physical therapy referral. The primary care provider should provide an official referral, which is crucial for initiating the treatment process. After obtaining the official referral, the nurse should provide the physical therapist with the client's medical record. This step is essential for the therapist to assess the client's condition and customize the treatment plan accordingly. Once the physical therapist is informed and prepared, the nurse can then transport the client to the physical therapy room for treatment. Therefore, the correct sequence is to first contact the primary care provider (Choice C), then provide the medical record (Choice B), and finally transport the client for treatment (Choice A). Choice D, suggesting the client self-refer to the physical therapist, is incorrect as the referral process should involve healthcare professionals to ensure proper assessment and treatment planning.

2. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?

• A. Notify maintenance to come and check the pump immediately.
• B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
• C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
• D. Tag the equipment for maintenance.

Correct answer: C

Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.

3. Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:

• A. hypothalamus.
• B. thalamus.
• C. cortex.
• D. medulla.

Correct answer: A

Rationale: The hypothalamus is responsible for regulating sleep patterns among other functions. Injury to the hypothalamus can disrupt the sleep-wake cycle, leading to excessive sleepiness or changes in sleep patterns. Choices B, C, and D are incorrect as they do not primarily control sleep regulation. The thalamus is involved in relaying sensory information, the cortex is responsible for higher brain functions, and the medulla controls vital functions such as heartbeat and breathing.

4. A client is having a seizure; his blood oxygen saturation drops from 92% to 82%. What should the nurse do first?

• A. Open the airway.
• B. Administer oxygen.
• C. Suction the client.
• D. Check for breathing.

Correct answer: A

Rationale: When a client is having a seizure and their blood oxygen saturation drops significantly, the priority action for the nurse is to open the airway. This allows for adequate oxygenation and ventilation. Administering oxygen can come after ensuring the airway is clear. Suctioning the client should be done if there is an airway obstruction, and checking for breathing is part of the assessment but opening the airway takes precedence to ensure proper oxygenation and ventilation during a critical event like a seizure.

5. The client is unsure about making medical decisions as their disease progresses and wants to appoint someone to make these decisions. Which of the following options would be most appropriate?

• A. a living will
• B. informed consent
• C. a healthcare proxy
• D. non-informed consent

Correct answer: C

Rationale: The correct answer is 'a healthcare proxy.' A healthcare proxy involves the client appointing an individual to make medical decisions on their behalf if they become unable to do so. This option allows the client to choose someone they trust to act in their best interests. Choice A, 'a living will,' is a legal document that outlines a person's wishes regarding medical treatment in case they are unable to communicate their decisions. While it is important, it does not involve appointing someone to make decisions. Choice B, 'informed consent,' is a process where a healthcare provider explains a treatment or procedure, including its risks and benefits, to a patient who can then decide whether to proceed. This is not about appointing someone to make decisions on the patient's behalf. Choice D, 'non-informed consent,' is not a valid concept in healthcare. Informed consent is crucial for respecting a patient's autonomy and decision-making capacity.

Similar Questions