Nokea
The nurse triages phone calls for the primary healthcare provider (PHCP). Which client report requires immediate follow-up? A client reporting
- A. bilateral flank pain who has two nephrostomy tubes.
- B. abdominal cramping while instilling dialysate for peritoneal dialysis (PD).
- C. facial edema while being treated for nephrotic syndrome.
- D. a localized rash following the administration of ciprofloxacin for cystitis.
Correct Answer: C
Rationale: Facial edema in nephrotic syndrome (C) suggests worsening hypoalbuminemia or fluid overload, a medical emergency requiring immediate follow-up. Flank pain (A), dialysis cramping (B), and rash (D) are less urgent, as they are expected or manageable.
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The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. pancreatitis who has developed bruising around the umbilicus.
- B. a capillary blood glucose of 159 mg/dL (8.83 mmol/L) [70-110 mg/dL; 4-6 mmol/L] while receiving total parenteral nutrition.
- C. a blood pressure of 156/92 mmHg who sustained an ischemic stroke six hours ago.
- D. stable angina reporting headache while receiving nitroglycerin via transdermal patch.
Correct Answer: A
Rationale: Umbilical bruising in pancreatitis (A) suggests Cullen’s sign, indicating possible retroperitoneal hemorrhage, a life-threatening emergency. Mild hyperglycemia (B), elevated BP post-stroke (C), and nitroglycerin headache (D) are less urgent, as they are expected or manageable.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG).
- B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools.
- C. diabetes mellitus who refuses to eat following the administration of glargine insulin.
- D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Black, tarry stools in a client on warfarin (B) suggest gastrointestinal bleeding, a life-threatening complication requiring immediate assessment. Respiratory acidosis (A) is concerning but less acute if stable. Refusing to eat post-insulin (C) risks hypoglycemia but is less urgent. Pancreatitis pain (D) rated 3/10 is manageable.
A mental health clinic is being constructed in a local community. A nurse manager is hired to facilitate the unit’s nursing policies. Which of the following is the best resource for these policies?
- A. Code of Ethics
- B. Nurse Practice Act
- C. Patient’s Bill of Rights
- D. Rights for the Mentally Ill
Correct Answer: B
Rationale: The Nurse Practice Act (B) defines legal scope and standards for nursing practice, making it the best resource for policy development. Code of Ethics (A), Patient’s Bill of Rights (C), and Rights for the Mentally Ill (D) guide but lack specific operational details.
The nurse has been made aware of the following client situations. The nurse should first assess the client
- A. with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 90%.
- B. being treated for hypertension and has a blood pressure of 151/95 mm Hg and complains of a headache.
- C. with a urinary catheter in place who is experiencing fever and chills.
- D. with a chest tube attached to a closed-chest drainage system that reports the onset of dyspnea.
Correct Answer: D
Rationale: Dyspnea with a chest tube (D) suggests complications like tube occlusion or pneumothorax, requiring immediate assessment to ensure airway and breathing stability. COPD saturation (A), hypertension with headache (B), and catheter-related fever (C) are less urgent.
The registered nurse (RN) is observing licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Positions an unconscious client semi-Fowlers for oral care
- B. Administers a bronchodilator to a client with chronic asthma
- C. Irrigates an indwelling urinary catheter with 30 ml of sterile saline
- D. Removes and reapplies weight to a client's skin traction every two hours
- E. Administers intramuscular (IM) ketorolac to a client with osteoarthritis
Correct Answer: A
Rationale: Positioning an unconscious client in semi-Fowler’s for oral care (A) risks aspiration, requiring intervention. Bronchodilator (B), catheter irrigation (C), traction adjustment (D), and ketorolac administration (E) are within LPN scope if per protocol.