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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. Page a chaplain on call to be present for questions.
- D. Ask the family to identify a specific spokesperson.
Correct Answer: D
Rationale: Identifying a spokesperson streamlines communication, reducing confusion and repetitive questions.
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The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat and sleeps most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?
- A. Maintain in high Fowler's position.
- B. Report any change in urine color.
- C. Keep mucous membranes moist.
- D. Record the client's daily weight.
Correct Answer: C
Rationale: Keeping mucous membranes moist prevents discomfort and complications, a priority in palliative care.
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.
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.
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?
- A. Discuss why visitors should not lie in the bed with the client.
- B. Notify the charge nurse that the visitor is lying on the client's bed.
- C. Explain that the client has the right to have a visitor lie on the bed.
- D. Instruct the UAP to ask the visitor to get off the client's bed.
Correct Answer: D
Rationale: Instructing the UAP to address the visitor maintains hygiene and safety efficiently.
The nurse leading a care team on a medical surgical unit is assigning client care to a practical nurse (PN) and an unlicensed assistive personnel (UAP). Which activity should the nurse assign to the PN?
- A. Evaluate and update plans of care for clients.
- B. Complete comprehensive assessments.
- C. Determine the need for urinary catheterizations.
- D. Measure preoperative clients for elastic stocking size.
Correct Answer: C
Rationale: Determining the need for catheterizations is within the PN's scope, requiring clinical judgment suitable for their training.