Nokea
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 the nursing staff to evacuate ambulatory clients to the nearest fire exits.
- B. Instruct unlicensed assistive personnel (UAPs) to transfer all non-ambulatory clients via wheelchairs.
- C. Announce in a calm voice that all visitors should proceed immediately to the first floor via the service elevators.
- D. Shut all doors to client rooms and tell everyone to stay in their rooms until the fire department arrives.
Correct Answer: A
Rationale: Evacuating ambulatory clients to fire exits prioritizes their safety, following standard fire evacuation protocols.
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A male college student is brought to an emergency clinic by his friends because they report that he has been vomiting for the past two days as a result of food poisoning. Laboratory findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor client's electrocardiogram continuously.
- B. Inject prescribed potassium chloride IV push slowly.
- C. Assess level of consciousness every 4 hours.
- D. Instruct client on dietary intake of potassium-rich foods.
Correct Answer: A
Rationale: Continuous ECG monitoring is critical due to hypokalemia's risk of causing life-threatening arrhythmias.
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.
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.
An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor, demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?
- A. Discuss with the family about placing the client in a skilled care facility.
- B. Determine if the client is manifesting other neurologic changes.
- C. Apply a restraining device to prevent the client from self injury.
- D. Request family members report when the client is left alone.
Correct Answer: B
Rationale: Assessing for neurologic changes identifies potential causes of agitation, such as delirium or hypoxia.
The healthcare provider discusses with a male client the need for a cardiac catheterization, describes the risks and benefits of the procedure, and asks the nurse to have the client sign the consent form. When the nurse presents the consent form for signature, the client hesitates and asks the nurse how the wires will keep his heart going. Which action should the nurse take?
- A. Call the client's next of kin and have them provide verbal consent.
- B. Explain the procedure again in detail and clarify any misperceptions.
- C. Notify the healthcare provider of the client's lack of understanding.
- D. Postpone the procedure until the client understands the risks/benefits.
Correct Answer: C
Rationale: Notifying the provider ensures the client's misunderstanding is addressed for valid informed consent.