Nokea
A nurse is assessing four clients on a medical-surgical unit. Which of the following clients should the nurse care for first?
- A. A client who has pneumonia and has an axillary temperature of 38° C (101° F)
- B. A client who has diarrhea and requests clear liquids for breakfast
- C. A client who has a cast on the left leg and reports numbness and paresthesia
- D. A client who has type 1 diabetes mellitus and has a fasting blood glucose level of 150
Correct Answer: C
Rationale: The correct answer is C because numbness and paresthesia in a client with a cast can indicate compartment syndrome, a medical emergency requiring immediate attention to prevent tissue damage or loss of limb. This condition can lead to permanent disability if not addressed promptly. Clients with pneumonia (choice A) and elevated temperature can be managed with antipyretics and antibiotics, while a client with diarrhea (choice B) requesting clear liquids can be managed with dietary adjustments. A client with type 1 diabetes and a blood glucose level of 150 (choice D) may require insulin adjustment but is not as urgent as addressing potential compartment syndrome.
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A nurse is caring for a client who is experiencing alcohol withdrawal. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Monitor the client's vital signs every 4 hours.
- B. Administer a prescribed benzodiazepine.
- C. Assess the client for tremors or agitation.
- D. Provide the client with a quiet environment.
Correct Answer: D
Rationale: The correct answer is D: Provide the client with a quiet environment. This task can be delegated to an assistive personnel (AP) because it involves creating a suitable environment for the client, which does not require specialized nursing skills. Assisting the client in a quiet environment can help minimize triggers and promote calmness during alcohol withdrawal.
A: Monitoring vital signs every 4 hours requires nursing judgment to interpret the results and decide on appropriate interventions.
B: Administering a benzodiazepine is a medication administration task that should be done by a nurse who can assess the client's condition and response to the medication.
C: Assessing the client for tremors or agitation involves clinical judgment and requires a nurse's expertise to determine the appropriate interventions.
In summary, providing a quiet environment is a task that can be safely delegated to an assistive personnel, while the other options involve assessments, medication administration, and clinical judgment that are within the scope of nursing practice.
A nurse manager is observing the care provided by a nurse who is in orientation to the unit. Which of the following actions by the nurse indicates the nurse manager should intervene?
- A. The nurse opens the top flap of a sterile tray toward the body when assisting the provider with a thoracentesis.
- B. The nurse uses clean gloves when discontinuing a client's intravenous infusion.
- C. The nurse uses the client's telephone number as one form of identification when administering medications to a client.
- D. The nurse empties a client's drainable colostomy pouch when it is one-third full.
Correct Answer: C
Rationale: The correct answer is C. Using a client's telephone number as identification is a violation of privacy and confidentiality. It is not a secure or reliable form of identification and could lead to errors in medication administration. The other choices do not indicate immediate intervention is needed. A: Opening the top flap of a sterile tray is incorrect but may not cause immediate harm. B: Using clean gloves for discontinuing an IV infusion is incorrect, but can be corrected easily. D: Emptying a colostomy pouch when it is one-third full is appropriate to prevent skin irritation and leakage.
A nurse is caring for a client who is postoperative. Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply
- A. Medication for elevated temperature
- B. Insertion of NG tube for decompression
- C. Oxygen 2 to 4 L/min via nasal cannula
- D. Insertion of urinary catheter
- E. Evaluation of surgical wound drain
Correct Answer: A,E
Rationale: The correct choices are A and E. Requesting medication for an elevated temperature (choice A) is important as it indicates a potential sign of infection postoperatively. Evaluation of the surgical wound drain (choice E) is crucial to monitor for any signs of infection or complications. Choices B, C, and D are not appropriate for an SBAR report as they do not directly address postoperative care needs. NG tube insertion (choice B) and urinary catheter insertion (choice D) are invasive procedures that should not be requested without a specific indication. Oxygen therapy (choice C) may be necessary but is not the priority in this case.
A charge nurse is planning care for a unit with limited staffing due to a flu outbreak. Which of the following actions should the charge nurse prioritize?
- A. Assign assistive personnel to provide client education on hand hygiene.
- B. Ensure all clients receive their scheduled baths on time.
- C. Reassess clients with unstable vital signs every 2 hours.
- D. Delegate documentation of intake and output to the unit clerk.
Correct Answer: C
Rationale: The correct answer is C: Reassess clients with unstable vital signs every 2 hours. This is the priority because clients with unstable vital signs require frequent monitoring to detect any deterioration or changes in their condition promptly. This action directly impacts patient safety and allows for timely intervention if needed.
Assigning assistive personnel for client education (A) is important for infection control but may not be the priority during a staffing shortage. Ensuring scheduled baths (B) is important for hygiene but can be delayed if necessary. Delegating documentation of intake and output (D) to the unit clerk is not appropriate as it involves clinical judgment and assessment.
A nurse is caring for a client who is postoperative following a total knee replacement. The client reports numbness in the operative leg. Which of the following actions should the nurse take first?
- A. Administer a prescribed analgesic.
- B. Notify the provider of the numbness.
- C. Elevate the client's leg on pillows.
- D. Document the client's report in the medical record.
Correct Answer: B
Rationale: Notifying the provider of numbness is critical, as it may indicate a complication such as nerve damage or compartment syndrome, requiring immediate evaluation.