Nursing Elites

1. When planning care for a client with vision loss, which of the following interventions should the nurse include in the plan of care to assist the client with feeding?

• A. Arrange food in a consistent pattern on the client's plate
• B. Thicken liquids on the client's tray
• C. Provide small-handled utensils for the client
• D. Assign a staff member to feed the client

Correct answer: A

Rationale: When a client has vision loss, arranging food in a consistent pattern on the plate can help them locate and identify different food items more easily. This intervention promotes independence and allows the client to feed themselves with greater ease. Thicking liquids on the tray, providing small-handled utensils, or assigning a staff member to feed the client may not directly address the client's need for assistance with feeding due to vision loss. Thicking liquids is more related to swallowing difficulties, providing small-handled utensils can be helpful for clients with limited dexterity, and assigning a staff member to feed the client may not promote independence.

2. Upon noticing a visitor who is loud and active and carrying a gun on the unit where you are in charge, what should you do immediately?

• A. Ask the visitor to leave.
• B. Talk quietly to calm the visitor.
• C. Ask the visitor for the gun.
• D. Notify security with the details of the situation.

Correct answer: D

Rationale: In a situation where a visitor arrives on the unit with a gun, it is essential to prioritize the safety of patients and staff. Immediately notifying security with all the relevant details is the correct course of action. Asking the visitor to leave or engaging them could escalate the situation and put everyone at risk. Similarly, requesting the gun from the visitor directly is not advisable as it could lead to a dangerous confrontation. By alerting security promptly, you enable trained professionals to handle the situation safely and effectively, minimizing risks and ensuring the safety of all individuals involved.

3. 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.

4. The healthcare provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?

• A. Avoid snacking at bedtime.
• B. Increase the rapid-acting insulin dose.
• C. Check the blood glucose during the night.
• D. Administer a larger dose of long-acting insulin.

Correct answer: C

Rationale: The Somogyi effect, also known as rebound hyperglycemia, occurs due to an excessive insulin dose at night, leading to hypoglycemia in the early morning hours. To address this, the nurse should instruct the patient to check their blood glucose during the night to determine if hypoglycemia is present, which triggers the rebound hyperglycemia. By monitoring blood glucose levels during the night, the patient can identify if adjustments are needed to prevent this phenomenon and maintain stable glucose levels. Choices A, B, and D are incorrect. Avoiding snacking at bedtime, increasing rapid-acting insulin dose, or administering a larger dose of long-acting insulin are not appropriate actions to manage the Somogyi effect. Checking blood glucose during the night is crucial to identify and prevent the rebound hyperglycemia characteristic of this phenomenon.

5. Which of the following is one of the sources used to determine the reason for voluntary turnover?

• A. Following-up phone calls
• B. Employee questioning
• C. Benchmarking
• D. Exit interviewing

Correct answer: D

Rationale: The correct answer is 'D: Exit interviewing.' Exit interviews are a crucial source used to determine the reasons for voluntary turnover. During exit interviews, departing employees provide valuable insights into their reasons for leaving, which can help organizations identify areas for improvement. Choices A, B, and C are incorrect. Following-up phone calls and benchmarking are not commonly used methods for determining the reasons behind voluntary turnover. While employee questioning can be a part of the exit interview process, the primary source mentioned in the context of voluntary turnover is exit interviewing.

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