Nokea
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. Ask the family to identify a specific spokesperson.
- D. Page a chaplain on call to be present for questions.
Correct Answer: C
Rationale: Designating a spokesperson streamlines communication, reducing repetitive questions and respecting client privacy. Individual questioning, provider involvement, or chaplain support are less immediate solutions.
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The charge nurse in an emergency center is planning client care assignments for the staff. Which action may be safely delegated to the practical nurse (PN)?
- A. Provide client with resources and discharge teaching
- B. Educate the clients about prescribed dietary changes.
- C. Establish blood pressure parameters for client monitoring
- D. Reinforce diet teaching for discharge to home
Correct Answer: D
Rationale: Reinforcing diet teaching is within the PN's scope, reviewing prior RN education. Providing resources, educating on diet changes, and setting BP parameters require RN judgment.
A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be hooked up to any machines. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation 88%. Which action should the nurse take?
- A. Obtain the client's legal records for power of attorney.
- B. Give analgesic medications as needed (PRN).
- C. Discontinue the intravenous infusion.
- D. Ask the palliative care team to speak with the client.
Correct Answer: D
Rationale: Consulting palliative care respects the client's wish to avoid machines and provides holistic end-of-life support. Power of attorney, analgesics, and IV discontinuation are secondary or inappropriate.
The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
- A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
- B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
- C. Renal transplant yesterday, complaining of flank pain and who states, 'it's hot in here.'
- D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
To help prevent by a dissatisfied client, which objective is most important to include in the orientation classes for staff nurses? New nursing staff members will
- A. demonstrate how to complete an adverse occurrence or variance report.
- B. discuss how to handle complaints from clients and/or their families.
- C. describe how to obtain legal services if needed.
- D. maintain personal malpractice insurance.
Correct Answer: B
Rationale: Teaching nurses to handle complaints effectively can prevent escalation to litigation by resolving conflicts early. Completing variance reports, obtaining legal services, or maintaining insurance are important but less preventive than addressing complaints directly.
The nurse receives a change-of-shift report from the prior nurse assigned to a group of clients on a post-surgical unit. Which client requires the most immediate intervention by the nurse?
- A. A client who had an abdominal-perineal resection 3 days ago has no drainage on the dressing and is reporting chills.
- B. A client who fell from a ladder and has a collapsed left lower lung with 100 mL drainage in a chest tube collection container.
- C. A client who was admitted 4 hours ago with a gunshot wound and has a dressing with 2 cm-sized dark red drainage.
- D. A client who is post-mastectomy 2 days ago and has 50 mL of serosanguineous fluid in a Jackson-Pratt drain.
Correct Answer: A
Rationale: The client with no drainage and chills may have an infection or sepsis, which are life-threatening complications requiring immediate assessment and physician notification. The chest tube drainage is normal, the gunshot wound drainage is not excessive, and the mastectomy drain output is expected, making these less urgent.