Nokea
A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?
- A. I will sign as a witness to your signature.'
- B. Because it is a legal document, you will need to find a witness on your own.'
- C. Whoever is present at the time will sign as a witness for you.'
- D. I will contact the nursing supervisor for assistance regarding your request.'
Correct Answer: D
Rationale: Contacting the nursing supervisor (D) ensures compliance with legal witnessing requirements, as nurses may be restricted due to conflict of interest. Signing as a witness (A), leaving it to the client (B), or allowing anyone present (C) risks legal issues.
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The charge nurse is planning client care assignments for the medical-surgical unit. Which client should the charge nurse assign to the nurse floated from labor and delivery? A client
- A. receiving a continuous infusion of heparin for pulmonary embolism.
- B. eight hours post-operative following an open appendectomy.
- C. with a water-seal chest tube for a pneumothorax.
- D. admitted with an exacerbation of congestive heart failure (CHF).
Correct Answer: B
Rationale: A post-operative appendectomy client (B) is stable and aligns with labor and delivery nurses’ skills in post-surgical care. Heparin infusion (A), chest tube (C), and CHF exacerbation (D) require specialized medical-surgical expertise.
The nurse has received the following information about assigned clients. The nurse should initially assess the client who is at
- A. 15 weeks gestation who reports not feeling any fetal movement.
- B. 28 weeks gestation who reports swollen feet and ankles.
- C. 36 weeks gestation who reports contractions that are irregular.
- D. 37 weeks gestation experiencing variable decelerations.
Correct Answer: D
Rationale: Variable decelerations at 37 weeks (D) indicate possible umbilical cord compression, a fetal emergency requiring immediate assessment. No fetal movement at 15 weeks (A) is normal, edema at 28 weeks (B) is common, and irregular contractions at 36 weeks (C) are non-urgent.
The nurse is caring for a client who has just returned from receiving a hemodialysis treatment. It would require immediate follow-up by the nurse if the client has
- A. a temperature (T) of 99.4°F (37.4°C).
- B. restlessness and a headache.
- C. weight loss of 3 kilograms (6.6 pounds).
- D. persistent fatigue.
Correct Answer: B
Rationale: Restlessness and headache post-hemodialysis (B) suggest disequilibrium syndrome or hypotension, critical complications requiring immediate follow-up. Mild fever (A), weight loss (C), and fatigue (D) are expected or less urgent.
The nurse is caring for a client with symptomatic sinus bradycardia. The nurse should recognizes that the priority action should is be to taken?
- A. review the client's most recent serum potassium level.
- B. document the findings.
- C. notify the severity rapid response team.
- D. continue monitoring the client's vital signs
- E. B
Correct Answer: C
Rationale: Symptomatic sinus bradycardia (B) requires immediate notification of the rapid response team (C) to address potential hemodynamic instability. Documenting (A), monitoring (B), or reviewing labs (D) delays critical intervention.
The nurse is caring for the following assigned clients. The nurse should initially follow-up on the client who
- A. is taking lithium that reports nausea and vomiting.
- B. is refusing their prescribed quetiapine.
- C. is reporting a headache following the first dose of citalopram.
- D. gets drowsy following a dose of alprazolam.
Correct Answer: A
Rationale: Nausea and vomiting with lithium (A) suggest potential toxicity, requiring immediate follow-up. Quetiapine refusal (B), headache with citalopram (C), and drowsiness with alprazolam (D) are less urgent or expected side effects.