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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. Explain that the family has a right to know of potential health problems.
- B. Advise the client to weigh all possible outcomes prior to the decision.
- C. Suggest to the family the value of genetic screening.
- D. Notify the health department of the client's condition.
Correct Answer: B
Rationale: Advising the client to weigh outcomes supports their autonomy while encouraging informed decision-making.
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The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?
- A. Call for an assistant.
- B. Respond to the code.
- C. Close the room door.
- D. Finish the procedure.
Correct Answer: A
Rationale: Calling for an assistant maintains the lumbar puncture's safety while allowing the nurse to address the code promptly.
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. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
- D. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
Correct Answer: C
Rationale: A UAP checking for fecal impaction is outside their scope, requiring immediate reassignment to a nurse.
The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?
- A. 30 mL of serous fluid obtained from compression bulb device in last 4 hours.
- B. 40 mL per hour of dark, cloudy urine from urinary catheter in last 4 hours.
- C. 20 mL of serosanguinous drainage from chest tube in last 8 hours.
- D. No observable drainage from 3-day-old Penrose drain in last 8 hours.
Correct Answer: D
Rationale: No drainage from a Penrose drain may indicate obstruction or infection, requiring immediate assessment.
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. Determine if the client has an as needed (PRN) prescription for an antianxiety agent.
- D. Close the door to the room to avoid disturbing other clients in nearby rooms.
Correct Answer: B
Rationale: Removing restraints prioritizes the client's autonomy and safety, avoiding harm from inappropriate use.
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.