A nurse is providing education about when health care referrals would be appropriate. When should a healthcare provider order a referral?

When the unit is too busy.

When the care needed for the client is out of their scope of practice.

When the client doesn’t have insurance.

When the client is late.

Answer and Explanation

The Correct Answer is B

Choice A reason: Referring a client because the unit is too busy is not an appropriate reason for a healthcare referral. Referrals should be based on the client’s specific needs and the expertise required to address those needs. Overcrowding or busyness of a unit should be managed through internal resources and staffing adjustments rather than referrals.

Choice B reason: When the care needed for the client is out of the healthcare provider’s scope of practice, a referral is necessary. This ensures that the client receives the appropriate level of care from a specialist or another provider with the required expertise. Referrals help in providing comprehensive and specialized care that the initial provider may not be equipped to deliver.

Choice C reason: Referring a client because they do not have insurance is not appropriate. Healthcare providers should assist clients in finding resources and support for their care needs, regardless of their insurance status. Referrals should be based on clinical needs, not financial or insurance considerations.

Choice D reason: Referring a client because they are late is not a valid reason for a healthcare referral. Timeliness is important, but it should not determine the need for a referral. Providers should address the reasons for lateness and work with the client to ensure they receive the necessary care.

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Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to drink more fluids is a primary intervention for managing thick respiratory secretions. Adequate hydration helps to thin the mucus, making it easier to expectorate. Fluids such as water, herbal teas, and clear broths are particularly effective. The normal daily fluid intake for an adult is about 2-3 liters, depending on individual needs and health conditions.

Choice B reason: Getting a prescription for an antitussive agent is not the best initial approach for managing thick respiratory secretions. Antitussive agents are used to suppress coughing, which can be counterproductive when trying to clear mucus from the respiratory tract. Instead, expectorants or mucolytics are more appropriate as they help to thin and loosen the mucus.

Choice C reason: Teaching effective deep breathing is beneficial for overall lung health and can help in mobilizing secretions. However, it is not as immediately effective as increasing fluid intake for thinning thick secretions. Deep breathing exercises can be part of a comprehensive respiratory care plan but should be combined with other interventions like hydration.

Choice D reason: Changing the patient’s position every 2 hours is a good practice for preventing complications such as pressure ulcers and promoting lung expansion. However, it is not specifically targeted at thinning thick respiratory secretions. Positional changes can aid in the drainage of secretions but are secondary to ensuring adequate hydration.

A. The client has full range of motion in her wrist. B. The client is attempting to remove the restraint. C. The client has cyanotic digits. D. The client denies discomfort.

Correct Answer is C

Explanation

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.

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A nurse is providing education about when health care referrals would be appropriate. When should a healthcare provider order a referral?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is complaining of thick respiratory secretions that are difficult to clear. What should the nurse encourage the client to do to help clear those secretions?

Correct Answer is A

Explanation

A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

Correct Answer is C

Explanation

A nurse received a prescription to administer a medication NOW to a client. Which action should the nurse take?

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which measure is important for the nurse to take?

A nurse is assessing for jaundice on a dark-skinned client. Which site should the nurse examine to identify jaundice on this client?

A nurse is confirming with the client the informed consent signed earlier that day. The client then states, “I have changed my mind and do not want to have the procedure done.” What action should the nurse take?

The nurse is caring for a newborn requiring a life-saving blood transfusion. The parents are practicing Jehovah’s Witnesses and refuse the transfusion. Who would the nurse consult for assistance in this situation?

The nurse is recommending guided meditation as a nonpharmacological pain intervention for a client experiencing chronic pain. What information should the nurse include when teaching the client about nonpharmacological pain interventions?

A nurse is teaching a class about palliative care. The nurse should include that which of the following is the focus of palliative care?