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1. Staff are sometimes injured when a patient or visitor becomes agitated. If a staff member reports an injury, the following actions should take place: (EXCEPT)
- A. Notify security.
- B. Complete an incident report.
- C. Notify the nursing supervisor.
- D. Ensure that staff has been examined.
Correct answer: B
Rationale: When a staff member reports an injury resulting from an agitated patient or visitor, several actions should be taken. These actions include notifying security to ensure safety, notifying the nursing supervisor for appropriate follow-up, and ensuring that the injured staff member has been examined to assess the extent of the injury. Completing an incident report is not the correct action to exclude because documenting the incident is crucial for legal and healthcare purposes. Incident reports provide a detailed account of what occurred, which is essential for investigations, insurance claims, and improving safety protocols. Therefore, all other options are necessary steps to take when a staff member reports an injury, making completing an incident report the correct answer for exclusion.
2. In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take?
- A. Determine what type of activities the patient enjoys.
- B. Remind the patient that exercise will improve self-esteem.
- C. Teach the patient about the effects of exercise on glucose levels.
- D. Give the patient a list of activities that are moderate in intensity.
Correct answer: A
Rationale: The correct answer is to determine what type of activities the patient enjoys. This approach is crucial as it helps in personalizing the exercise plan to the patient's preferences, making it more likely for them to adhere to it. Choice B is incorrect because focusing on self-esteem may not directly motivate the patient to engage in exercise. Choice C, although important, may not be the initial step as understanding the patient's preferences comes first. Choice D limits the patient's autonomy by not involving them in the decision-making process.
3. A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to
- A. save the lunch tray for the patient�s later return to the unit
- B. ask that diagnostic testing area staff to start a 5% dextrose IV
- C. send a glass of milk or orange juice to the patient in the diagnostic testing area
- D. request that if testing is further delayed, the patient be returned to the unit to eat.
Correct answer: D
Rationale:
4. What is the primary focus of a performance appraisal for nursing staff?
- A. To identify areas for salary increases
- B. To evaluate overall job performance
- C. To provide feedback on clinical skills
- D. To determine eligibility for promotions
Correct answer: C
Rationale: The primary focus of a performance appraisal for nursing staff is to provide feedback on clinical skills, identify areas for improvement, and support professional development. While salary increases, overall job performance evaluation, and promotions may be factors considered during a performance appraisal, the primary goal is to assess and enhance clinical skills to ensure high-quality patient care.
5. In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?
- A. Ensure sterilization of nondisposable items with ethylene oxide.
- B. Wear hypoallergenic latex gloves that do not contain powder.
- C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
- D. Wrap monitoring cords with stockinette and tape them in place.
Correct answer: B
Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. When a client has a latex allergy, it is crucial to avoid direct contact with latex-containing products to prevent an allergic reaction. Choosing hypoallergenic latex gloves that are powder-free reduces the risk of the client being exposed to latex allergens. Option A is incorrect because using ethylene oxide for sterilization does not directly address the client's latex allergy. Option C is incorrect because cleansing latex ports with chlorhexidine does not eliminate the risk of latex exposure. Option D is incorrect as it does not specifically address the issue of latex allergy during the procedure.
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