Nokea
A charge nurse is reviewing documentation in the medical record from a newly licensed nurse. Click to highlight the findings that indicate this nurse requires additional education.
- A. The client is inappropriate and is a huge fall risk
- B. The provider has denied this RN's requests for physical or chemical restraints
- C. They appear 'medically stable
- D. the partner is at bedside and said that their spouse is always complaining or arguing
- E. Morphine 10mg IV given orally
- F. The client has a history of major depressive disorder and alcohol use disorder
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. A indicates the nurse's lack of understanding of patient safety by not recognizing the fall risk. B suggests a lack of knowledge on restraint alternatives. C shows an inadequate assessment of the patient's overall condition. D reflects poor communication skills and lack of understanding of family dynamics. Choices E and F are not necessarily indicative of a need for additional education based on the information provided.
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A nurse has received change-of-shift report and is delegating tasks to the assistive personnel (AP). The nurse should tell the AP to complete which of the following tasks first?
- A. Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast.
- B. Apply a condom catheter to a client who is incontinent.
- C. Deliver a clean voided urine specimen to the laboratory.
- D. Feed a client who has bilateral casts due to upper arm fractures.
Correct Answer: A
Rationale: The correct answer is A: Perform blood glucose monitoring of a client who has a prescription for short-acting insulin prior to breakfast. This task should be completed first because it involves monitoring a client's blood glucose level to ensure safe administration of insulin. Insulin administration is time-sensitive and should be based on current blood glucose levels to prevent hypoglycemia or hyperglycemia. This task directly impacts the client's immediate health and safety, making it the priority.
Summary of other choices:
B: Applying a condom catheter can be important but is not as time-sensitive or critical as monitoring blood glucose levels for insulin administration.
C: Delivering a clean voided urine specimen is important but can often wait until after more urgent tasks are completed.
D: Feeding a client with bilateral casts is important, but it is not as time-sensitive as monitoring blood glucose levels for insulin administration.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
- A. A middle adult male who is diaphoretic and reports epigastric pain
- B. A toddler who has a laceration on his forehead and is screaming
- C. An adolescent female client who is belligerent and has slurred speech
- D. A young adult with a painful sunburn of his face and arms
Correct Answer: A
Rationale: The correct answer is A. The nurse should have the provider care for the middle adult male who is diaphoretic and reports epigastric pain immediately. Diaphoresis and epigastric pain can be signs of a heart attack or other serious cardiac issue, requiring urgent medical attention to prevent complications. The other choices do not present an immediate life-threatening situation. The toddler with a laceration can be addressed after stabilizing the critical client. The belligerent adolescent may need behavioral intervention but does not require immediate medical attention. The young adult with sunburn, while painful, is not a life-threatening condition that requires immediate provider care.
A nurse is preparing to administer a prescribed medication to a client. Which of the following actions should the nurse plan to take to demonstrate client advocacy?
- A. Insist the client take prescribed medications.
- B. Inform the client that the medication is the same as taken at home.
- C. Tell the client that refusal of the medication is considered noncompliance.
- D. Encourage the client to verbalize questions.
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to verbalize questions. This demonstrates client advocacy as it empowers the client to actively participate in their care, promotes informed decision-making, and ensures understanding of the medication. This approach respects the client's autonomy and right to make informed choices. It also allows the nurse to address any concerns or misconceptions the client may have, leading to better adherence to the treatment plan.
Incorrect choices:
A: Insisting the client take prescribed medications goes against the principles of client autonomy and informed consent.
B: Simply informing the client about the medication without addressing their questions or concerns does not actively involve the client in their care.
C: Labeling the client's refusal as noncompliance can be seen as judgmental and does not encourage open communication or shared decision-making.
A nurse manager is reviewing the admission history of four adults who were admitted to the medical-surgical unit during the shift. Which of the following situations is the nurse required to disclose information to an outside agency about the client or the client's circumstances?
- A. A young adult client admitted for acute glomerulonephritis following a viral infection
- B. A dependent adult admitted for the treatment of a spiral fracture
- C. A young adult client admitted for asthma and has track marks that may indicate IV drug abuse
- D. An emancipated minor who has acute appendicitis and wants to leave the facility without treatment
Correct Answer: B
Rationale: The correct answer is B because a dependent adult admitted for the treatment of a spiral fracture falls under mandatory reporting requirements for suspected abuse or neglect. The nurse is obligated to disclose information to an outside agency to ensure the safety and well-being of the patient. In cases of suspected abuse or neglect, it is crucial to involve external agencies to investigate and protect the vulnerable adult.
Choices A, C, and D do not necessarily involve mandatory reporting to an outside agency. A young adult with glomerulonephritis or asthma with possible IV drug abuse may not require immediate disclosure unless there is a clear indication of harm or risk to the patient. An emancipated minor with acute appendicitis wanting to leave without treatment raises ethical concerns but may not involve mandatory reporting unless there are specific legal requirements in place.
A nurse is reviewing admission assessment and plan of care for a client who has Crohn's disease. Admission Assessment
A 20-year-old admitted through emergency department who is experiencing an exacerbation of previously diagnosed Crohn's disease. Client has lost 6.8 kg (15 lb) over the past week and is too nauseated to keep anything down today. They noticed blood in their stool three days ago. Repeatedly stated to staff, "I do not want to live like this. I am totally frustrated with all you medical people."
Assessment:
Right lower quadrant abdominal pain, abdominal bloating, diarrhea (mucus and blood present), perianal abscess.
Vital Signs:
Temperature 37.5° C (99.5° F)
Heart rate 78/min
Respiratory rate 20/min
Blood pressure 102/54 mm/Hg
Provider Prescriptions
Medical management
CBC, CMP. ESR (erythrocyte sedimentary rate)
MRE (magnetic resonance enterography) of pelvis and abdomen
Corticosteroids for clinical finding management. Taper dose as indicated.
Gastrointestinal evaluation
Nutritional screening and management
Screen for depression
Smoking cessation program
Follow CDC recommended immunizations for those on immunosuppressive therapies.
Evaluate for possible surgical management.
A nurse is reviewing admission assessment and plan of care for a client who has Crohn's disease. Which members of the interdisciplinary team should the nurse anticipate being included the plan of care? Select all that apply.
- A. Occupations Therapist
- B. General Surgeon
- C. Physical Therapist
- D. Radiologist
- E. Registered Dietitian
- F. Gastroenterologist
- G. Speech Therapist
Correct Answer: B,D,E,F
Rationale: The correct answer includes a General Surgeon, Radiologist, Registered Dietitian, and Gastroenterologist. General Surgeon is essential for surgical interventions in severe cases. Radiologist helps in diagnostic imaging. Registered Dietitian assists in managing the client's nutritional needs given the impact of Crohn's disease on digestion. Gastroenterologist specializes in treating gastrointestinal issues like Crohn's disease. The other choices are incorrect because: A) Occupational Therapist primarily focuses on helping individuals engage in meaningful activities, which may not be directly related to managing Crohn's disease. C) Physical Therapist focuses on physical rehabilitation, not the primary focus in managing Crohn's disease. G) Speech Therapist is not typically included in the interdisciplinary team for managing Crohn's disease.