Nokea
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 rate is 88%. Which action should the nurse take?
- A. Obtain the client's legal records for power of attorney.
- B. Ask the palliative care team to speak with the client.
- C. Give analgesic medications as needed (PRN).
- D. Discontinue the intravenous infusion.
Correct Answer: B
Rationale: Consulting palliative care aligns with the client's wishes, focusing on symptom relief and quality of life.
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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 provides the client's signed power of attorney and a home medication list. When reporting to the healthcare provider using SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Client's healthcare power of attorney.
- B. Increasing confusion of the client.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: B
Rationale: Increasing confusion is the urgent situation, indicating potential neurological deterioration.
It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client?
- A. A business executive admitted with Guillain-Barre syndrome who has residual bilateral numbness in the lower extremities.
- B. A woman who is pregnant with twins and whose due date is one week away.
- C. An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dL (22 mmol/L).
- D. A 2-year-old who contracted Hepatitis A while at a local daycare center.
Correct Answer: C
Rationale: The elderly client with a broken hip and uncontrolled diabetes requires urgent, coordinated care to manage multiple acute conditions.
A staff nurse has been tardy for morning shift assignments for the past three days and provides no explanation for arriving late. Which approach is best for the nurse manager to use when addressing this staff member's tardiness?
- A. Offer to switch the nurse's shift assignments to afternoons or evenings.
- B. Stress the expectation that the nurse will arrive on time for all scheduled shifts.
- C. Caution the nurse that one more tardiness will result in probational employment.
- D. Have the nurse sign a copy of the hospital employee attendance policy.
Correct Answer: B
Rationale: Stressing the expectation of punctuality clearly communicates standards and promotes accountability.
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.
Which staff assignment, made by the primary nurse, requires the most immediate follow-up action by the charge nurse on a medical unit?
- A. A practical nurse is assigned to transport a postoperative client to the rehabilitation unit.
- B. A practical nurse (PN) is assigned to monitor the blood pressure of a client with hypertension.
- C. An unlicensed assistive personnel (UAP) is assigned to check a client for fecal impaction.
- D. A graduate nurse is assigned to obtain a unit of packed red blood cells from the blood bank.
Correct Answer: C
Rationale: A UAP checking for fecal impaction is outside their scope, requiring immediate reassignment to a nurse.