Nokea
The nurse has received report on the assigned night-shift clients. Which client should the nurse see first?
- A. a mildly confused client due for a dressing change on a diabetic ulcer to the heel
- B. an elderly, stable client who just returned from an MRI to rule out a kidney mass
- C. a client whose IV pump has started beeping, indicating that the antibiotic has completed infusing
- D. a client complaining of sudden warmth and pain at an appendectomy incision site 48 hours after surgery
Correct Answer: D
Rationale: Sudden warmth and pain at a surgical site 48 hours post-surgery may indicate infection or dehiscence, requiring immediate assessment. Options A, B, and C describe less urgent situations.
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The nurse is caring for a client on the orthopedic unit who had a total knee replacement on the left side. The nurse knows the client will be ready for discharge when she is able to do which of the following activities?
- A. ambulate 100 feet with crutches or walker
- B. get up and down a flight of stairs
- C. flex the surgical knee 30 degrees
- D. fix a snack
Correct Answer: A
Rationale: Ambulating 100 feet with assistive devices indicates sufficient mobility and strength for safe discharge. Stair climbing and full knee flexion are typically longer-term goals, and fixing a snack is unrelated to surgical recovery.
A toddler in gastric distress is admitted to the pediatric intensive care unit. The toddler becomes anxious and tries to remove the IV. The mother offers to help calm the child. Which action by the nurse is most appropriate?
- A. paint a smiley face on the dressing covering the IV site
- B. give the child a puzzle to complete
- C. ask the mother to read the child's favorite book
- D. administer a sedative to the child
Correct Answer: C
Rationale: Reading a favorite book is age-appropriate and leverages maternal comfort to reduce anxiety without medication.
A nurse on a busy surgical floor is working with an unlicensed assistive personnel (UAP). The nurse understands that which task cannot be delegated to the UAP?
- A. assisting a stable client to set up her meal tray for easy access
- B. assisting a client with an arm cast onto the bedpan
- C. calling report on a client who is being transferred to the observation floor
- D. helping a client ambulate in the hall who is post-op day 2 from a cardiac catheterization with stent placement
Correct Answer: C
Rationale: Calling report requires nursing judgment and is outside the UAP's scope.
The nurse reports to work and finds that a client from the previous day has been assigned to another nurse. The nurse had a great rapport with the client and wonders how he did during the night. She decides to look at the client's chart to read the progress notes. Which statement is correct regarding the nurse's actions?
- A. She should go to the client's room and see how he is doing.
- B. She has legal access to the client's chart since she was involved in his care.
- C. The nurse is violating HIPAA regulations and should not be accessing the client's chart.
- D. She should wait and ask the other nurse how the client is doing and not view the client's chart.
Correct Answer: C
Rationale: Accessing the chart without a care-related need violates HIPAA, as the nurse is no longer assigned to the client.