Nokea
The nurse is working triage in the ED when four clients present at the same time. Which client should be seen first?
- A. a 45-year-old female on oral contraceptives with unusually heavy menstrual bleeding
- B. a 24-year-old with a dog bite to the leg from the family dog who is current on rabies shots
- C. an irritable 4-month-old with a petechial rash, nuchal rigidity, and temperature of 103.4°F
- D. a 16-year-old football player with a twisted ankle who has no deformity and a pedal pulse
Correct Answer: C
Rationale: A 4-month-old with a petechial rash, nuchal rigidity, and high fever suggests possible meningitis, a life-threatening condition requiring immediate attention. Options A, B, and D are less urgent.
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A client undergoes total shoulder replacement on the left shoulder. Which statements by the client indicates he requires further teaching? Select all that apply.
- A. I look forward to soaking in my hot tub when I get home from surgery.
- B. The surgery will eliminate my pain within 24 hours.
- C. I will receive therapy for several weeks after my surgery.
- D. Walking is an exercise I'll be able to do after surgery.
Correct Answer: A,B
Rationale: Soaking in a hot tub risks infection, and expecting pain elimination within 24 hours is unrealistic. Therapy is expected, and walking is an appropriate exercise.
The nurse in the senior dementia unit noticed an increase in client falls over the last six months. She worked with other unit nurses and the nurse manager to develop a new fall risk assessment tool and updated the unit policies regarding falls. Which activity did the nurse engage in?
- A. delegation
- B. peer review
- C. consultation
- D. client referral
- E. quality improvement
Correct Answer: E
Rationale: Developing a new assessment tool and updating policies is a quality improvement initiative to enhance client safety.
Which assignment made by a charge nurse should be questioned?
- A. a student nurse assigned to a newly admitted child with acute leukemia who is receiving a blood transfusion
- B. an RN assigned to a teenaged child diagnosed recently with bacterial meningitis
- C. a CNA assigned to a stable male client who is 3 days post-stroke
- D. an LPN assigned to a newly admitted child with acute leukemia who is receiving IV fluids
Correct Answer: A
Rationale: A student nurse lacks the experience to manage a transfusion, which requires close monitoring for reactions.
A nurse is talking to a nursing student about quality improvement and nurse-sensitive indicators. The nurse knows that the nursing student understands quality improvement when she identifies which to be nurse-sensitive indicators? Select all that apply.
- A. fall injury rates
- B. restraint utilization rates
- C. staying within the unit budget
- D. upgrading computer charting programs
- E. pressure ulcer prevalence and incidence
- F. client satisfaction with pain management
Correct Answer: A,B,E,F
Rationale: Fall injuries, restraint use, pressure ulcers, and pain management satisfaction are nurse-sensitive indicators, directly tied to nursing care quality.