Nokea
The nurse is caring for a 7-year-old child who presents to the ED with multiple bruises, a fractured ankle, and cigarette burns on the arms. Which action by the nurse is most appropriate?
- A. ask the parents if they burned the child with cigarettes
- B. ask the client to tell you what happened to cause the bruising and burns
- C. inform the parents that they cannot leave with the child until they talk to the police
- D. notify the charge nurse immediately so that the suspected child abuse can be reported
Correct Answer: D
Rationale: Suspected child abuse, indicated by bruises, fractures, and burns, requires immediate reporting to the charge nurse for further action, as nurses are mandated reporters. Options A, B, and C may delay reporting or escalate the situation inappropriately.
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A newly graduated nurse has completed hospital orientation and has just started working with her own clients. Which of the following assignments is most appropriate for this nurse?
- A. a nonverbal client hospitalized for seizures
- B. a client undergoing peritoneal dialysis at the bedside
- C. a client who had a negative heart catheterization the day before
- D. an elderly client who just returned from surgery for a below-the-knee amputation
Correct Answer: C
Rationale: The stable post-catheterization client requires routine care, suitable for a new graduate. The other assignments involve complex or unstable conditions.
The nurse is caring for a client when the attending physician comes in to round on the client. At the nurses' station, the nurse smells alcohol on the physician's breath when he hands her the chart with new orders. Which action by the nurse is appropriate?
- A. notify the nurse manager and or/charge nurse
- B. confront the physician about the smell of alcohol
- C. tell the client and request a consult with another physician
- D. enter the new orders as written, since there was only a morning lab draw ordered
Correct Answer: A
Rationale: Notifying the nurse manager ensures proper handling of a potential impairment issue without direct confrontation or breaching client trust.
An 84-year-old adult male requires nonurgent surgery. The client is considered to have diminished decision-making capacity due to a diagnosis of Alzheimer's. The nurse questions his ability to provide informed consent for the procedure. The best action for the nurse to take in this situation is which of the following?
- A. as this is nonurgent surgery with few risks, allow the client to sign the consent form
- B. contact administrative personnel for a determination consistent with hospital policy
- C. have the client's 54-year-old second cousin sign the consent form
- D. request the physician sign the consent form
Correct Answer: B
Rationale: Hospital policy guides consent for clients with diminished capacity, ensuring legal and ethical compliance. A cousin is not automatically a surrogate, and physicians cannot sign consent.
The nurse is caring for a client admitted for right-sided renal artery stenosis. Where should the nurse anticipate auscultating for a renal bruit?
- A. right renal artery
- B. right iliac artery
- C. left renal artery
- D. left iliac artery
Correct Answer: A
Rationale: A bruit from right-sided renal artery stenosis is auscultated over the right renal artery, near the mid-abdomen.