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A nurse in a provider's office is reviewing the laboratory findings for a client who is scheduled for surgery. Which of the following findings requires follow up by the nurse?
- A. WBC 6,000/mm3
- B. BUN 15 mg/dL
- C. Hemoglobin 14 g/dL
- D. Platelet count 60,000/mm3
Correct Answer: D
Rationale: The correct answer is D: Platelet count 60,000/mm3. A low platelet count (thrombocytopenia) can increase the risk of bleeding during surgery. Normal platelet count is around 150,000-450,000/mm3. The other options are within normal ranges: A) WBC 6,000/mm3 is normal, B) BUN 15 mg/dL is normal, and C) Hemoglobin 14 g/dL is normal. Therefore, the nurse should follow up on the platelet count to ensure the client's safety during surgery.
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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 delegating tasks to an assistive personnel (AP) for a client with a pressure injury. Which of the following tasks is appropriate for the AP to perform?
- A. Assess the stage of the pressure injury.
- B. Reposition the client every 2 hours.
- C. Apply a prescribed wound dressing.
- D. Evaluate the client's skin integrity.
Correct Answer: B
Rationale: Repositioning the client every 2 hours is a routine task that helps prevent further skin breakdown and is within the AP's scope of practice. Assessment, dressing application, and evaluation require nursing judgment.
A nurse is caring for a client who is experiencing chest pain. Which of the following actions should the nurse take first?
- A. Administer prescribed nitroglycerin.
- B. Obtain a 12-lead ECG.
- C. Notify the provider of the chest pain.
- D. Assess the client's pain characteristics.
Correct Answer: D
Rationale: Assessing the client's pain characteristics provides critical data to guide further actions, such as medication administration or diagnostic testing, and is the first step in managing chest pain.
A nurse is teaching a class on torts. The nurse should instruct the class that administering an antibiotic medication to a competent client after the client has refused it is an example of which of the following torts?
- A. False imprisonment
- B. Assault
- C. Battery
- D. Negligence
Correct Answer: C
Rationale: The correct answer is C: Battery. Battery is the intentional harmful or offensive touching of another person without consent. In this scenario, administering the antibiotic medication to a competent client after they have refused it constitutes a deliberate act of touching the client without their consent, which aligns with the definition of battery.
False imprisonment (A) involves restricting a person's freedom of movement unlawfully, which does not apply in this case. Assault (B) involves the threat of harmful or offensive contact, not the actual act itself. Negligence (D) is the failure to exercise proper care in a situation, which is not applicable here as the action was intentional.
A charge nurse is making assignments for nursing personnel who will be caring for clients during the oncoming shift. Which of the following factors should the charge nurse consider?
- A. The physiologic status of the clients on the unit
- B. Social relationships between nurses working the oncoming shift
- C. Personal comfort level in making the assignments
- D. The most experienced nurse receives the more complex clients
Correct Answer: A
Rationale: The correct answer is A. The charge nurse should consider the physiologic status of the clients on the unit when making assignments to ensure that each client receives appropriate care based on their health condition. This factor is crucial for patient safety and outcomes. Choice B is incorrect as social relationships between nurses should not influence patient assignments. Choice C is incorrect as personal comfort level should not drive assignment decisions, rather patient needs should. Choice D is incorrect as assigning more complex clients based solely on experience may not always be the best approach, as other factors like workload and skill mix should also be considered.