Nokea
A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?
- A. The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.
- B. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dL (10.8 mmol/L).
- C. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
- D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
Correct Answer: D
Rationale: The pneumothorax client with low oxygen saturation is at risk of respiratory failure, requiring immediate assessment.
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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.
A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family provides the client's signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Client's healthcare power of attorney.
- B. Increasing confusion of the client.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: B
Rationale: Increasing confusion is the urgent situation, indicating potential neurological deterioration.
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take?
- A. Ensure transfer of the client's electronic chart code.
- B. Give a detailed report to accepting nurse.
- C. Give client written information about end-of-life care.
- D. Take the family to the client's new room.
Correct Answer: B
Rationale: A detailed report ensures continuity of care, critical for the client's palliative needs.
The nurse observes a practical nurse (PN) placing a client on the right side with the left leg bent in preparation for a lumbar puncture. Which action should the nurse implement?
- A. Assume care of the client and assign the PN to the care of a different client.
- B. Acknowledge that the PN has positioned the client safely and correctly.
- C. Arrange for an unlicensed assistive personnel to assist the PN during the procedure.
- D. Demonstrate to the PN how to position the client more effectively for the procedure.
Correct Answer: D
Rationale: Demonstrating proper positioning corrects the error, educates the PN, and ensures client safety during the procedure.
The healthcare provider prescribes an oral medication to be given daily for 3 days. However, the medication was also given on the fourth day. Which intervention is most important for the charge nurse to implement?
- A. Review the medication transcription with the nurse.
- B. Evaluate the client for symptoms of a drug interaction.
- C. Report the medication error to the nursing supervisor.
- D. Inform the pharmacist who dispensed the medication.
Correct Answer: C
Rationale: Reporting the error ensures proper documentation and follow-up for client safety.