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A client with tachycardia and hypotension presents to the emergency department (ED) reporting severe vomiting and diarrhea for three days. Which action is most important for the nurse to implement?
- A. Monitor for impending signs of shock.
- B. Initiate enteric precaution procedures.
- C. Reduce light, noise and temperature.
- D. Encourage electrolyte supplements.
Correct Answer: A
Rationale: Monitoring for signs of shock is critical due to the client's dehydration and fluid volume deficit, which could lead to organ failure. Enteric precautions, environmental adjustments, and electrolyte supplements are important but secondary to preventing life-threatening shock.
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A fire is reported in the kitchen on the first floor of a three-floor community hospital, and the operator notifies the charge nurse on the third floor to start evacuation procedures. Which intervention should the charge nurse implement?
- A. Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
- B. Instruct the nursing staff to evacuate ambulatory clients to the nearest fire exits.
- C. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
- D. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
Correct Answer: C
Rationale: Shutting doors and keeping everyone in rooms follows the RACE protocol (Rescue, Alarm, Contain, Extinguish), containing the fire and protecting from smoke. Evacuating clients or using elevators during a fire risks exposure to danger.
A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family requests an update on the client's condition. Using the SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Increasing confusion of the client.
- B. Client's healthcare power of attorney.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: A
Rationale: The current situation (increasing confusion) is the first step in SBAR, addressing the family's immediate concern. Power of attorney, medications, and fall history are provided later in the communication.
An adult client is admitted via the Emergency Department with a head injury that will initially require intensive care. Which role is responsible for coordinating the progression of this client's care through rehabilitation and discharge?
- A. Nurse case manager.
- B. Adult nurse practitioner.
- C. Neurology unit supervisor.
- D. Risk management nurse.
Correct Answer: A
Rationale: The nurse case manager coordinates the client's care continuum, collaborating with teams from admission to discharge. Other roles focus on specific care aspects, not overall coordination.
During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe an as needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. Which instruction should the nurse provide the unit clerk?
- A. Remain with this client and monitor the vital signs while the nurse takes the call.
- B. Ask the healthcare provider to remain on 'hold' until the nurse can confirm the prescription.
- C. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.
- D. Tell the healthcare provider the nurse will return the phone call as soon as possible.
Correct Answer: D
Rationale: The unit clerk cannot take verbal orders; instructing the provider to be called back ensures the nurse handles the prescription directly. Monitoring vitals, holding the call, or writing orders are inappropriate for the clerk's role.
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.