Nokea
A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?
- A. Notify the health department of the client's condition.
- B. Advise the client to weigh all possible outcomes prior to the decision.
- C. Suggest to the family the value of genetic screening.
- D. Explain that the family has a right to know of potential health problems.
Correct Answer: B
Rationale: Advising the client to consider outcomes respects her autonomy while encouraging informed decision-making. Notifying the health department, suggesting screening, or asserting family rights violate confidentiality or autonomy.
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After reviewing the morning laboratory findings for four clients, which client should the nurse follow up with first? Reference Range: International Normalized Ratio [0.8 to 1.1], Blood Glucose 74 to 106 mg/dL (4.1 to 5.9 mmol/L)], Potassium [3.5 to 5 mEq/L (3.5 to 5 mmol/L)], Brain Natriuretic Peptide (BNP) [less than 100 pg/mL (less than 100 ng/L)]
- A. The brain natriuretic peptide (BNP) assay for a client with shortness of breath after a myocardial infarction (MI) increases to 1000 pg/mL (1000 ng/L).
- B. The international normalized ratio (INR) for a client who is receiving warfarin therapy increases to 2.5.
- C. The serum glucose level for a client receiving corticosteroids increases to 150 mg/dL (8.3 mmol/L).
- D. The potassium level for a client scheduled for renal dialysis increases to 5 mEq/L(5 mmol/L).
Correct Answer: A
Rationale: A BNP of 1000 pg/mL indicates severe heart failure, requiring urgent interventions like oxygen and diuretics. The INR is therapeutic, glucose is mildly elevated, and potassium is normal, making these less urgent.
Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
- A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.
- B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
- C. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
- D. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
Correct Answer: D
Rationale: Checking for fecal impaction is beyond the UAP's scope, risking client injury. The other assignments (transport, BP monitoring, blood retrieval) are within the respective staff's competencies.
A charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?
- A. A client with multisystem failure secondary to a motor vehicle collision.
- B. A client in end-stage liver failure who is experiencing esophageal bleeding.
- C. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
- D. A client with chest tubes secondary to a stab wound to the chest.
Correct Answer: D
Rationale: The client with chest tubes has stable needs manageable by a new graduate with recent training. Multisystem failure, liver failure, and ARDS require advanced skills better suited to experienced nurses.
The nurse manager observes that the staff nurse has used wrist restraints to help secure an elderly female in her wheelchair. The client is pleading for the nurse to release her arms. The nurse explains to the nurse manager that the client needs to be restrained in the wheelchair so that the nurse can change her bed linens. Which is the priority action by the nurse manager?
- A. Contact the healthcare provider to ensure that a prescription for restraints was written.
- B. Advise the staff nurse to remove the restraints from the client's wrists.
- C. Close the door to the room to avoid disturbing other clients in nearby rooms.
- D. Determine if the client has an as needed (PRN) prescription for an antianxiety agent
Correct Answer: B
Rationale: Removing restraints is the priority as they are unjustified for staff convenience and violate client rights. Checking for a prescription, closing the door, or considering antianxiety medication do not address the immediate ethical and safety concerns.
Several nurses are elected by their peers to serve on a negotiating committee to recommend new healthcare benefits. After the new benefits plan is developed and approved, which action is most important for the nurses working on this committee to implement?
- A. Announce the new plan at a special employee wellness event.
- B. Determine staff opinion of current healthcare insurance costs.
- C. Survey the nurses to see who wants to keep the old benefits plan.
- D. Be available to all shifts to discuss the changes in health benefits.
Correct Answer: D
Rationale: Being available to discuss changes ensures clear communication and addresses concerns across all shifts, fostering acceptance. Announcing at an event, assessing current costs, or surveying preferences are less critical post-approval.