Nokea
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control.
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Which client requires the most immediate intervention by the nurse?
- A. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- B. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6 F (38.1 C).
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: A
Rationale: Somnolence in acute kidney injury suggests uremic encephalopathy, requiring immediate neurological assessment.
An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first?
- A. Consult the palliative care team.
- B. Obtain a do not resuscitate prescription.
- C. Define the term heroic measures.
- D. Coordinate a family conference.
Correct Answer: B
Rationale: Obtaining a DNR prescription legally documents the client's wishes, a priority action.
The registered nurse (RN) is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the emergency department (ED) nurse calls to report on a client with unstable angina who must be admitted immediately. A practical nurse (PN) and unlicensed assistive personnel (UAP) are available to the RN. How should the RN assign the necessary nursing actions?
- A. Assign the UAP to prepare the room while the PN obtains report on the new admission and the RN assists with the thoracentesis.
- B. Assign the UAP to assist with the thoracentesis while the PN goes to the ED to transport the client to the unit and the RN obtains report from the ED nurse.
- C. Assign the PN to assist with the thoracentesis while the RN obtains report and the UAP prepares the room for the new admission.
- D. Assign the PN to go to the ED to obtain report and transport the client while the UAP prepares the room and the RN assists with the thoracentesis.
Correct Answer: D
Rationale: The PN can handle report and transport, the UAP can prepare the room, and the RN is needed for the thoracentesis.
A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
- A. Let each family member ask a question one at a time.
- B. Request the healthcare provider to speak with the family.
- C. Page a chaplain on call to be present for questions.
- D. Ask the family to identify a specific spokesperson.
Correct Answer: D
Rationale: Identifying a spokesperson streamlines communication, reducing confusion and repetitive questions.
A group of nurse managers is asked to engage in a needs assessment for a piece of equipment that will be expensed to the organization's budget. Which question is most important to consider when analyzing the cost-benefit for this piece of equipment?
- A. How many departments can use this equipment?
- B. Can the equipment be updated each year?
- C. Is the cost of equipment reasonable?
- D. Will the equipment require annual repair?
Correct Answer: C
Rationale: Determining if the cost is reasonable directly evaluates the equipment's value against its benefits, critical for budget decisions.