Nokea
A nurse is assessing an older adult client who was brought to the emergency department by his son, who reports that the client fell at home. The nurse suspects elder abuse. Which of the following actions should the nurse take?
- A. File an incident report.
- B. Ask the client about his injuries with the son present.
- C. Ask the client's son to go to the waiting area.
- D. Treat and discharge the client
Correct Answer: C
Rationale: The correct action for the nurse to take is to ask the client's son to go to the waiting area. This allows the nurse to interview the client independently to assess for signs of elder abuse without the son's potential influence. Filing an incident report may be necessary later but is not the immediate action required. Asking about injuries with the son present could lead to biased responses or intimidation. Treating and discharging the client without addressing the suspicion of elder abuse would neglect the nurse's responsibility to ensure the client's safety.
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A patient's serum potassium level is 2.2 mEq/L. Which nursing action is the highest priority for this patient?
- A. Start oxygen at 2 L/min
- B. Initiate cardiac monitoring
- C. Initiate seizure precautions
- D. Keep the patient on bed rest
Correct Answer: B
Rationale: The correct answer is to initiate cardiac monitoring. Severe hypokalemia can lead to life-threatening arrhythmias, making cardiac monitoring the priority to detect and manage any cardiac complications. Starting oxygen, seizure precautions, or bed rest are not the immediate priority actions for severe hypokalemia.
What is the normal sodium level in the body?
- A. 135 to 145 milliequivalents per liter.
- B. 3 to 5 milliequivalents per liter.
- C. 135 to 145 microequivalents per liter.
- D. 3 to 5 microequivalents per liter.
Correct Answer: A
Rationale: The correct answer is A: 135 to 145 milliequivalents per liter. The normal range for sodium levels in the body is expressed in milliequivalents per liter, not microequivalents. Choice B and D provide a significantly lower range which is not within the normal values for sodium. Choice C incorrectly states 'microequivalents' instead of the correct unit 'milliequivalents'. Therefore, A is the correct answer.
Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?
- A. Administer glyburide again
- B. Administer subcutaneous insulin and monitor blood glucose
- C. Monitor blood glucose closely, and look for signs of hypoglycemia
- D. Monitor blood glucose and assess for signs of hyperglycemia
Correct Answer: C
Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.
Which of the following is the best argument for lower patient-to-nurse ratio?
- A. The more patients a nurse has, the better the nurse will be at catching early warning signs.
- B. Greater patient-to-nurse ratios decrease patient mortality.
- C. Adequate nurse levels do not impact the prevalence of urinary tract infections.
- D. Community nursing ratios do not impact Methicillin-resistant Staphylococcus aureus (MRSA) rates.
Correct Answer: B
Rationale: The best argument for lower patient-to-nurse ratios is that they decrease patient mortality. Choice A is incorrect because having more patients can lead to increased workload and decreased attention per patient. Choice C is incorrect as adequate nurse levels can indeed impact the prevalence of infections. Choice D is incorrect as community nursing ratios can impact MRSA rates due to potential transmission risks in healthcare settings.
A nurse manager observes an assistive personnel (AP) incorrectly transferring a client to the bedside commode. Which of the following should the nurse take first?
- A. Refer the AP to the facility procedure manual
- B. Demonstrate the proper client transfer technique for the AP
- C. Instruct the AP to request assistance when unsure about a task
- D. Help the AP assist the client with the transfer
Correct Answer: D
Rationale: The correct first action for the nurse is to ensure the safety of the client by immediately intervening to help the AP with the transfer. This hands-on assistance can prevent any potential harm to the client. Referring the AP to the facility procedure manual (Choice A) might take time and delay the necessary immediate action. Demonstrating the proper technique (Choice B) can be done after ensuring the client's safety. Instructing the AP to request assistance (Choice C) is not the most urgent step when a client's safety is at risk.