Nokea
A mental health clinic is being constructed in a local community. A nurse manager is hired to facilitate the unit’s nursing policies. Which of the following is the best resource for these policies?
- A. Code of Ethics
- B. Nurse Practice Act
- C. Patient’s Bill of Rights
- D. Rights for the Mentally Ill
Correct Answer: B
Rationale: The Nurse Practice Act (B) defines legal scope and standards for nursing practice, making it the best resource for policy development. Code of Ethics (A), Patient’s Bill of Rights (C), and Rights for the Mentally Ill (D) guide but lack specific operational details.
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The nurse is planning client assignments for a licensed practical/vocational nurse (LPN/VN). Which client assignment would be appropriate? A client
- A. in an arm cast who is suspected to have compartment syndrome.
- B. immediately post-operative from a prostate resection reporting bladder spasms.
- C. with a paralytic ileus requiring the insertion of a nasogastric tube.
- D. newly diagnosed with Hepatitis A and requires discharge teaching.
Correct Answer: B, D
Rationale: LPNs can manage stable clients with bladder spasms post-prostate resection (B) and provide discharge teaching for Hepatitis A (D), within their scope. Compartment syndrome (A) requires RN assessment for urgent intervention, and NG tube insertion (C) is typically an RN task due to complexity.
The nurse is observing practices in the behavioral health unit. Which of the practices should the nurse question?
- A. Opening all client's postal packages prior to giving them to the client.
- B. Reviewing the process of how a client may lodge a formal complaint.
- C. Allowing clients to communicate over the telephone in a private area.
- D. Allowing clients who are involuntarily admitted to refuse prescribed medication(s).
Correct Answer: D
Rationale: Allowing involuntarily admitted clients to refuse medications (D) should be questioned, as court-ordered treatment may require compliance. Opening packages (A) ensures safety, complaint processes (B) are standard, and private calls (C) respect privacy.
The registered nurse (RN) is working with two licensed/practical vocational nurses (LPN/VN) in the emergency department (ED). The RN assigns duties to one LPN/VN to administer prescribed medications for all clients and the other LPN/VN to perform medication reconciliation and obtain ordered 12-lead electrocardiograms (ECG). Which care delivery model is the RN utilizing?
- A. Team nursing
- B. Case management
- C. Functional nursing
- D. Primary nursing
Correct Answer: C
Rationale: Assigning specific tasks (medication administration, reconciliation, ECGs) to LPN/VNs (C) reflects functional nursing, where tasks are divided based on skill. Team nursing (A) involves collaborative care, case management (B) focuses on coordination, and primary nursing (D) assigns one nurse per client.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG).
- B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools.
- C. diabetes mellitus who refuses to eat following the administration of glargine insulin.
- D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Black, tarry stools in a client on warfarin (B) suggest gastrointestinal bleeding, a life-threatening complication requiring immediate assessment. Respiratory acidosis (A) is concerning but less acute if stable. Refusing to eat post-insulin (C) risks hypoglycemia but is less urgent. Pancreatitis pain (D) rated 3/10 is manageable.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. pancreatitis who has developed bruising around the umbilicus.
- B. a capillary blood glucose of 159 mg/dL (8.83 mmol/L) [70-110 mg/dL; 4-6 mmol/L] while receiving total parenteral nutrition.
- C. a blood pressure of 156/92 mmHg who sustained an ischemic stroke six hours ago.
- D. stable angina reporting headache while receiving nitroglycerin via transdermal patch.
Correct Answer: A
Rationale: Umbilical bruising in pancreatitis (A) suggests Cullen’s sign, indicating possible retroperitoneal hemorrhage, a life-threatening emergency. Mild hyperglycemia (B), elevated BP post-stroke (C), and nitroglycerin headache (D) are less urgent, as they are expected or manageable.