Nokea
A nurse enters a client's room and finds the client pulseless. The family has requested a do-not-resuscitate (DNR) order from the provider, but he has not written the order yet. Which of the following actions should the nurse take?
- A. Call the provider for a stat DNR order.
- B. Call the emergency response team.
- C. Seek immediate help from the risk manager.
- D. Respect the family's wishes and do nothing.
Correct Answer: B
Rationale: The correct answer is B: Call the emergency response team. In this scenario, the nurse encounters a pulseless client with pending DNR status. Calling the emergency response team is crucial as they are trained to assess the situation and provide appropriate interventions. It ensures that the client receives immediate assistance in a potentially life-threatening situation. Seeking a stat DNR order (choice A) may waste valuable time and delay necessary actions. Involving the risk manager (choice C) is not the priority when a client is pulseless. Simply respecting the family's wishes and doing nothing (choice D) goes against the nurse's duty to provide timely and appropriate care.
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A nurse in an emergency department receives report from an emergency responder who states a client is being transported following exposure to a 'dirty bomb'. The nurse should prepare to care for a client that has been exposed to which of the following types of agents?
- A. Radiologic
- B. Anthrax
- C. Chemical
- D. Sarin
Correct Answer: A
Rationale: The correct answer is A: Radiologic. A 'dirty bomb' combines conventional explosives with radioactive material, leading to radiologic exposure. The emergency responder's report of a 'dirty bomb' indicates potential radiation exposure. Choice B, Anthrax, is incorrect as it is a biological agent. Choice C, Chemical, is incorrect as it refers to exposure to toxic chemicals. Choice D, Sarin, is incorrect as it is a nerve agent. In summary, the nurse should prepare for radiologic exposure due to the 'dirty bomb' incident.
A nurse is triaging clients in an urgent care clinic. Which of the following clients should the nurse have the provider care for immediately?
- A. A middle adult male who is diaphoretic and reports epigastric pain
- B. A toddler who has a laceration on his forehead and is screaming
- C. An adolescent female client who is belligerent and has slurred speech
- D. A young adult with a painful sunburn of his face and arms
Correct Answer: A
Rationale: The correct answer is A. The nurse should have the provider care for the middle adult male who is diaphoretic and reports epigastric pain immediately. Diaphoresis and epigastric pain can be signs of a heart attack or other serious cardiac issue, requiring urgent medical attention to prevent complications. The other choices do not present an immediate life-threatening situation. The toddler with a laceration can be addressed after stabilizing the critical client. The belligerent adolescent may need behavioral intervention but does not require immediate medical attention. The young adult with sunburn, while painful, is not a life-threatening condition that requires immediate provider care.
A nurse in a provider's office is collecting a health history from a client who has a new prescription for glyburide to treat type 2 diabetes mellitus. Which of the following statements by the client indicates a contraindication for taking this medication?
- A. I had strep throat about one year ago.
- B. I got my flu shot at the pharmacy two weeks ago.
- C. I plan to continue nursing my baby until he is at least a year old.
- D. I am allergic to shellfish.
Correct Answer: C
Rationale: The correct answer is C. Glyburide is not recommended for use during breastfeeding as it can pass into breast milk and potentially harm the baby. Breastfeeding mothers should consult their healthcare provider for alternative medications. Choice A is unrelated, choice B and D are not contraindications for glyburide use.
A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
- A. A client who has COPD and the capillary refill time on both hands is 4 seconds
- B. A client who has late-stage cirrhosis and whose breath has a fruity odor
- C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
- D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the client who had an indwelling urinary catheter removed 5 hours ago and has not voided first. This situation raises concerns about urinary retention, which can lead to bladder distension, discomfort, and potential complications like urinary tract infections. Prompt assessment and intervention are necessary to prevent further issues.
Choice A is incorrect because a capillary refill time of 4 seconds in a client with COPD may suggest impaired circulation but is not as urgent as urinary retention. Choice B is incorrect as fruity odor in late-stage cirrhosis may indicate hepatic encephalopathy but is not an immediate priority. Choice C is incorrect as green gastric aspirate with a pH of 5.3 may indicate bile reflux but not as urgent as urinary retention.
A nurse is preparing to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks is appropriate for the LPN to perform?
- A. Develop a care plan for a client with a new diagnosis of diabetes.
- B. Administer a prescribed subcutaneous insulin injection.
- C. Perform an admission assessment for a client with chest pain.
- D. Evaluate the effectiveness of a client's pain management plan.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed subcutaneous insulin injection. LPNs are trained to administer medications, including insulin injections, under the supervision of a registered nurse or physician. LPNs have the knowledge and skills necessary to safely administer medications. Choices A, C, and D involve assessments, evaluations, and care planning, which are tasks typically performed by registered nurses. LPNs can assist with these tasks but should not independently perform them. Overall, LPNs are best suited to carry out tasks related to direct patient care, such as medication administration.