In a disaster situation, the nurse assessing a diabetic client on insulin assesses for all of the following except:

Correct Answer: C

Rationale: In a disaster situation, when assessing a diabetic client on insulin, the nurse should assess for diabetic signs and symptoms to monitor the client's condition, nutritional status to ensure proper dietary management, and availability of insulin to maintain the client's medication regimen. Bleeding problems are not directly related to diabetes or insulin use, making it the exception in this assessment scenario. Therefore, bleeding problems would not be a typical focus of assessment in this context.

Correct Answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

Correct Answer: D

Rationale: The nurse's primary responsibility after assigning tasks is to follow up with each staff member regarding the task's performance and outcomes. This ensures accountability and quality care delivery. Allowing staff members to make judgments independently can compromise patient safety if they lack the necessary knowledge or experience. While documenting task completion is important, it should follow the follow-up to assess outcomes. Assigning incomplete tasks to the next shift is not ideal as it may result in unmet patient needs and increased workload for the next shift.

Correct Answer: B

Rationale: To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.

Correct Answer: A

Rationale: The correct answer is 'Gathers supplies before beginning a task.' This action indicates a lack of effective time management because gathering supplies before starting a task can lead to inefficiency and time wastage. Effective time management involves organizing tasks efficiently, which includes having all necessary supplies ready before initiating a task. Allowing time for unexpected tasks, prioritizing client needs and daily tasks, and documenting task completion and client information at the end of the day are all essential components of good time management practices. Therefore, the new nursing graduate should focus on improving the timing of supply gathering to enhance time management skills. The other choices are not indicative of poor time management; instead, they demonstrate important aspects of effective time management in client care delivery.

Correct Answer: B

Rationale: Monitoring Serum Vancomycin levels is essential to determine the drug's therapeutic range, ensuring optimal effectiveness while avoiding toxicity. Peak levels indicate the drug's highest concentration, while trough levels represent the lowest concentration before the next dose. Assessing renal function is typically done using creatinine, BUN, or creatinine clearance tests, not Serum Vancomycin levels. Evaluating antibiotic resistance involves sensitivity testing, not monitoring Vancomycin levels. Therefore, the correct answer is to determine the therapeutic range.

Correct Answer: A

Rationale: The correct answer is the client scheduled for hemodialysis at 10 a.m. This client needs immediate assessment before the procedure, which may take up to 5 hours. The nurse should ensure the client is physically and emotionally prepared, check for fluid overload by assessing weight and lung sounds, review vital signs, and laboratory test results. The other clients described in the options have needs that are not as urgent. The client scheduled for a nuclear scanning procedure at 10 a.m. may require information reinforcement and increased fluid intake before the procedure. The client scheduled for hydrotherapy for the treatment of a burn injury at 10:30 a.m. may need pain medication administered 30 minutes prior to the therapy. The client scheduled for a contrast CT at noon may need procedure information reinforcement and a special contrast preparation just before the procedure.

Correct Answer: D

Rationale: The correct answer is 'Hispanic.' Hispanic individuals in the United States are at a higher risk for pesticide-related injuries due to their representation among migrant workers in agricultural settings. This exposure to pesticides in their work environments increases their risk compared to other ethnic groups. Choice A, 'Native American,' although indigenous populations may face environmental health disparities, the higher risk in this context is among Hispanic individuals. Choice B, 'Asian-Pacific,' and Choice C, 'Norwegian,' do not have the same level of exposure to pesticides as Hispanic migrant workers, making them less susceptible to pesticide-related injuries.

Correct Answer: A

Rationale: Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.