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A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
- A. Decreased level of consciousness
- B. Report of photophobia
- C. Increased temperature
- D. Generalized rash over trunk
Correct Answer: A
Rationale: The correct answer is A. A decreased level of consciousness in a client with meningitis indicates a severe neurological deterioration, possibly due to increased intracranial pressure. Immediate intervention is crucial to prevent further complications like brain damage or herniation. Reporting this to the provider facilitates prompt assessment and treatment. Choices B, C, and D are also common in meningitis but are not immediate concerns. Photophobia and increased temperature are typical symptoms, while a rash may indicate a different condition like viral exanthem.
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A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
- A. A client who has a raised red skin rash on his arms, neck, and face
- B. A client who has active bleeding from a puncture wound of the left groin area
- C. A client who reports right-sided flank pain and is diaphoretic
- D. A client who reports shortness of breath and left neck and shoulder pain
Correct Answer: B
Rationale: The correct answer is B, a client with active bleeding from a puncture wound of the left groin area. This is the highest priority because active bleeding can lead to severe blood loss, shock, and death if not controlled promptly. Immediate intervention is needed to stop the bleeding, assess for further injuries, and ensure the client's stability. Choices A, C, and D describe concerning symptoms that require attention but do not pose immediate life-threatening risks like uncontrolled bleeding. Therefore, they are of lower priority. It is crucial for the nurse to prioritize clients based on the severity and urgency of their conditions to provide timely and appropriate care.
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
- A. Assess the staff nurses' knowledge deficit.
- B. Demonstrate use of the pump during medication administration.
- C. Plan an in-service education program on the unit.
- D. Pair an inexperienced nurse with an experienced nurse.
Correct Answer: A
Rationale: The correct answer is A: Assess the staff nurses' knowledge deficit. This is the priority action because it helps identify the root cause of the difficulty with the new IV infusion pumps. By assessing the staff nurses' knowledge deficit, the charge nurse can determine if additional training, education, or support is needed. This step is crucial in addressing the problem effectively and ensuring safe medication administration.
Other choices:
B: Demonstrating the use of the pump during medication administration may be helpful but should come after assessing the knowledge deficit.
C: Planning an in-service education program is important but should be based on the assessment of the staff nurses' knowledge deficit.
D: Pairing an inexperienced nurse with an experienced nurse may be beneficial but does not directly address the underlying issue of knowledge deficit.
A nurse is supervising a newly licensed nurse who is performing surgical asepsis. After donning a sterile gown and gloves, which of the following actions by the newly licensed nurse demonstrates correct aseptic technique?
- A. The nurse puts on a face mask.
- B. The nurse turns her back to the sterile field.
- C. The nurse holds her hands above her waist.
- D. The nurse applies goggles.
Correct Answer: C
Rationale: Holding hands above the waist maintains sterility, as areas below the waist are considered non-sterile.
A nurse overhears two assistive personnel (AP) discussing a client's care in the cafeteria. Which of the following actions should the nurse take?
- A. Notify the client's provider about the incident.
- B. Instruct the AP to discontinue the conversation.
- C. Complete an incident report about the breach of client confidentiality.
- D. Reassign the AP to other clients on the unit.
Correct Answer: B
Rationale: The correct answer is B: Instruct the AP to discontinue the conversation. The nurse should address the situation immediately by instructing the AP to stop discussing the client's care in a public setting like the cafeteria to maintain client confidentiality. This action prevents further breach of confidentiality and reinforces the importance of respecting privacy. Notifying the provider (A) may be necessary later, but the immediate action should be to stop the conversation. Completing an incident report (C) is important for documentation but is not the first step. Reassigning the AP (D) may not address the root issue of confidentiality breach.
A client scheduled for a tubal ligation procedure starts to cry as she is wheeled into the surgical suite. Which of the following nursing statements is an appropriate nursing response?
- A. It's not too late to cancel the surgery if you want to.
- B. This won't take long and it will be over before you know it.
- C. Why did you make the decision to have this procedure?
- D. You shouldn't be worried because the procedure is very safe.
Correct Answer: A
Rationale: Correct Answer: A. "It's not too late to cancel the surgery if you want to."
Rationale: This response acknowledges the client's emotions and empowers her to make a decision based on her feelings. It shows empathy and respect for her autonomy in making choices about her own body.
Summary of Other Choices:
B: This response dismisses the client's emotions and may come off as insensitive.
C: Asking why the client made the decision can be perceived as judgmental and may increase anxiety.
D: This response invalidates the client's feelings and may not provide reassurance effectively.