Nokea
A nurse manager is assigning care of a client who is being admitted from the PACU following thoracic surgery. The nurse manager should assign the client to which of the following staff members?
- A. Charge nurse
- B. Registered nurse (RN)
- C. Practical nurse (PN)
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: In this scenario, a client who has undergone thoracic surgery and is being admitted from the PACU requires a high level of nursing care. Registered nurses (RNs) have the education and training necessary to provide the complex care and monitoring needed for a post-thoracic surgery client. Charge nurses may oversee units but may not always be directly involved in providing bedside care. Practical nurses (PNs) have a different scope of practice compared to RNs and may not have the advanced skills needed for post-thoracic surgery care. Assistive personnel (AP) provide valuable support but do not have the qualifications to manage the care of a client following thoracic surgery.
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A client is being treated for diabetic ketoacidosis (DKA). Which laboratory value would be most concerning?
- A. Blood glucose of 350 mg/dL
- B. Serum bicarbonate of 18 mEq/L
- C. Arterial pH of 7.20
- D. Serum potassium of 5.5 mEq/L
Correct Answer: C
Rationale: In a client with diabetic ketoacidosis (DKA), the most concerning laboratory value is an arterial pH of 7.20. An arterial pH of 7.20 indicates severe acidosis, which is a critical condition requiring immediate intervention. This pH level reflects a significant imbalance in the body's acid-base status, potentially leading to serious complications. High blood glucose levels (choice A) are expected in DKA but do not directly indicate the severity of acidosis. A serum bicarbonate level of 18 mEq/L (choice B) is low but not as immediately critical as a pH of 7.20. Serum potassium of 5.5 mEq/L (choice D) is elevated, which can occur in DKA due to insulin deficiency, but it is not the most concerning value in this scenario.
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?
- A. Pad the client's wrists before applying the restraints
- B. Tie the restraints to the side rails of the bed
- C. Secure the restraints to the bed frame
- D. Use a quick-release knot to tie the restraints
Correct Answer: A
Rationale: The correct action for the nurse to take when a client has a new prescription for wrist restraints is to pad the client's wrists before applying the restraints. This is important to prevent skin breakdown and injury. Tying the restraints to the side rails of the bed (Choice B) is unsafe and can lead to potential harm for the client. Similarly, securing the restraints to the bed frame (Choice C) is not appropriate as it can restrict the client's movement and cause discomfort. Using a quick-release knot to tie the restraints (Choice D) is also incorrect as it may compromise the effectiveness of the restraints in ensuring client safety.
At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence?
- A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel.
- B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery.
- C. It is OK if you don't want to talk about your surgery. I will be available when you are ready.
- D. I will ask a woman who has had a mastectomy to come by and share her experiences with you.
Correct Answer: C
Rationale: In this situation, it's essential to acknowledge and respect the client's feelings and choices. Choice C is the most appropriate response as it validates the client's decision not to discuss the surgery while offering support and understanding. Giving the client space and letting them know you will be available when they are ready shows empathy and fosters trust. Choices A and B do not respect the client's autonomy and may come across as dismissive or pressuring. Choice D assumes the client needs advice from someone who has had a similar experience without considering the client's current emotional state and preferences.
A nurse offers pain medication to a client who is postoperative before ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence involves actions intended to benefit the client, such as providing pain relief. In this scenario, the nurse is demonstrating beneficence by offering pain medication to alleviate the client's discomfort and promote their well-being. Fidelity (A) relates to being faithful to agreements and commitments, autonomy (B) refers to respecting a client's right to make decisions about their care, and justice (C) involves fairness and equal treatment. While these ethical principles are important in healthcare, the situation described primarily exemplifies the principle of beneficence.
A healthcare provider is preparing to perform mouth care for an unresponsive client. Which of the following actions should the healthcare provider plan to take?
- A. Raise the level of the bed
- B. Administer mouth care with the client in a supine position
- C. Use a tongue depressor to open the mouth
- D. Place the client in a prone position
Correct Answer: A
Rationale: Raising the bed level is the correct action to facilitate easier access for mouth care in an unresponsive client. This position enhances the safety and comfort of both the client and the healthcare provider. Administering mouth care with the client in a supine position (lying flat on their back) can increase the risk of aspiration. Using a tongue depressor to open the mouth is not recommended as it can cause discomfort and potential injury. Placing the client in a prone position (lying face down) is contraindicated for mouth care and can compromise the client's airway.