Nokea
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
You may also like to solve these questions
The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ('knocked out'). After recovering the tooth, the initial response should be to
- A. Rinse the tooth in water before placing it in the socket
- B. Place the tooth in a clean plastic bag for transport to the dentist
- C. Hold the tooth by the roots until reaching the emergency room
- D. Ask the child to replace the tooth even if the bleeding continues
Correct Answer: A
Rationale: Rinse the tooth in water before placing it in the socket. Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth in its socket within 30 minutes, avoiding contact with the root.
An 85-year-old woman is hospitalized with a fractured hip. She complains to the LPN/LVN that she feels something is wrong and her chest hurts. The nurse notes the client has tachypnea. What should the nurse do immediately?
- A. Administer oxygen
- B. Take vital signs
- C. Elevate the head of the bed
- D. Give aspirin
Correct Answer: B
Rationale: Chest pain and tachypnea suggest a possible pulmonary embolism post-hip fracture; taking vital signs provides critical data for immediate assessment.
The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?
- A. Reporting joint stiffness in the morning
- B. Taking the medication 1 hour before or 2 hours after meals
- C. Using alcohol in moderation unless driving
- D. Continuing to take aspirin for short term relief
Correct Answer: B
Rationale: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.
The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.
- A. I exhale for 2 seconds through pursed lips
- B. I exhale for 4 seconds through pursed lips
- C. I inhale for 2 seconds through my mouth
- D. I inhale for 2 seconds through my nose, keeping my mouth closed
- E. I inhale for 4 seconds through my nose, keeping my mouth closed
Correct Answer: B,D
Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.
A client is brought to the emergency room with injuries sustained in an auto accident. While performing his assessment, the nurse notes the presence of Cullen's sign. Cullen's sign is suggestive of:
- A. A neurological injury
- B. A ruptured spleen
- C. A bowel perforation
- D. Retroperitoneal bleeding
Correct Answer: D
Rationale: Cullen's sign, a bluish discoloration around the umbilicus, indicates retroperitoneal or intra-abdominal bleeding, often due to trauma or conditions like pancreatitis. It is not specific to neurological injury, spleen rupture, or bowel perforation.