Nokea
A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action?
- A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms.
- B. Ensure that a working IV pump is set up at the patient's bedside.
- C. Order a STAT arterial blood gas (ABG).
- D. Pad the side rails of the patient's assigned bed.
Correct Answer: D
Rationale: Padding the side rails (D) is the priority to prevent injury during ongoing or recurrent seizures in alcohol withdrawal, ensuring immediate safety. Requesting clonazepam (A) requires a physician order and is secondary, IV pump setup (B) is not urgent unless medication is ordered, and ABG (C) is unnecessary unless respiratory distress is present.
You may also like to solve these questions
A nurse is caring for a client who speaks a language different from the healthcare team. Which action by the nurse best ensures effective communication with the client?
- A. Using family members as interpreters.
- B. Utilizing a professional interpreter provided by the healthcare facility.
- C. Attempting to communicate using basic words and gestures.
- D. Referring the client to a language class for healthcare professionals.
Correct Answer: B
Rationale: A professional interpreter (B) ensures accurate, confidential communication, per Joint Commission standards. Family interpreters (A) risk bias, gestures (C) are unreliable, and language classes (D) are impractical for immediate needs.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN?
- A. A client requiring assistance picking out low potassium foods.
- B. A client requesting to leave the facility against medical advice (AMA).
- C. A client needing several prescriptions called into the local pharmacy.
- D. A client requesting breakthrough intravenous push (IV) pain medicine.
Correct Answer: A
Rationale: Assisting with low potassium food choices (A) is within the LPN’s scope, involving reinforcement of dietary teaching. AMA requests (B) and IV pain medication (D) require RN judgment, and calling prescriptions (C) may involve complex coordination.
The nurse performs a handoff report to the oncoming nurse for an older adult male in the intensive care unit (ICU). Which information is a priority to share with the oncoming nurse? The client
- A. has clear lung fields bilaterally with unlabored respirations.
- B. is forgetful and was not requesting assistance before getting out of bed.
- C. has a 20-gauge peripheral vascular access device that is patent and saline locked.
- D. has an indwelling urinary catheter that is patent with clear urine and is secured to the upper thigh.
Correct Answer: B
Rationale: Forgetfulness and not requesting help (B) indicate a high fall risk, a priority to share to ensure safety measures are in place. Clear lungs (A), patent IV (C), and urinary catheter (D) are stable and less urgent.
The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a
- A. collaborator
- B. team leader
- C. delegator
- D. manager
Correct Answer: A
Rationale: Collaborating with others across settings to achieve client-centered goals (A) defines the nurse’s role as a collaborator. Team leader (B) focuses on directing a group, delegator (C) assigns tasks, and manager (D) oversees operations, none of which fully capture this role.
The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first?
- A. Administer prescribed ibuprofen.
- B. Place the client on droplet precautions.
- C. Notify the public health department.
- D. Obtain prescribed blood cultures.
Correct Answer: B
Rationale: Placing the client on droplet precautions (B) is the first action for suspected meningitis (irritability, nuchal rigidity, fever) to prevent spread of infection. Administering ibuprofen (A), notifying public health (C), and obtaining blood cultures (D) are important but secondary to infection control.