Nokea
A nurse is assigned a group of clients at the start of the shift. Which of the following clients should the nurse plan to care for first?
- A. A client requesting a referral for home health services
- B. A client asking about his PCA pump that contains morphine
- C. A client who needs assistance with a bath
- D. A client who has questions about his new prescription
Correct Answer: B
Rationale: The correct answer is B. The nurse should plan to care for the client asking about his PCA pump with morphine first. This is because the client's inquiry relates to pain management, which is a priority in nursing care. Pain management directly impacts the client's comfort and well-being. Addressing the client's concerns about the PCA pump promptly ensures proper pain relief and prevents potential complications. Clients requesting referrals, assistance with baths, or questions about prescriptions can be attended to after the client with immediate pain management needs is addressed.
You may also like to solve these questions
A nurse manager observes an unknown man in a laboratory coat making copies of a client's medical record. Which of the following actions should the nurse plan to take first?
- A. Report the observation to the nurse caring for that client.
- B. Inform the nursing supervisor.
- C. Approach the man and ask why he is making copies.
- D. Notify hospital security.
Correct Answer: C
Rationale: The correct answer is C: Approach the man and ask why he is making copies. This is the first action the nurse should take to gather information and assess the situation. By directly addressing the man, the nurse can determine his intentions and potentially stop any unauthorized activity. Reporting to the nurse caring for the client (A) may lead to delays in addressing the issue directly. Informing the nursing supervisor (B) is important, but immediate action is needed. Notifying hospital security (D) should be done after gathering more information.
A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?
- A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min
- B. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
- C. A toddler who has otitis media, a temperature of 39.2 C (102.6° F), and purulent ear discharge
- D. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough
Correct Answer: D
Rationale: The correct answer is D. Acute epiglottitis is a medical emergency due to potential airway compromise. The child's drooling and absence of cough indicate a severe obstruction that can rapidly progress to complete airway closure. Immediate intervention is crucial to prevent respiratory distress or arrest. Choices A, B, and C have less urgent conditions that can be managed after ensuring the child with epiglottitis receives prompt care. Choice A, although having asthma, is stable with adequate oxygenation. Choice B, although in pain, can wait briefly for pain medication. Choice C, although having otitis media, does not present immediate life-threatening risk compared to epiglottitis.
A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
- A. Identify changes within the family unit that promote the client's autonomy.
- B. Gain 2 pounds of weight per week.
- C. Make positive statements about improvements in body image.
- D. Feel in control of her behavior.
Correct Answer: B
Rationale: The correct answer is B: Gain 2 pounds of weight per week. In anorexia nervosa, the primary goal is to restore the client's weight to a healthy level to prevent serious health complications. Weight restoration is crucial in addressing the physical consequences of severe malnutrition and improving overall health. Gaining weight at a steady pace of 2 pounds per week is a realistic and safe goal.
Other choices are incorrect because:
A: Identifying changes within the family unit is important but not the priority compared to addressing the physical health concerns.
C: Making positive statements about improvements in body image is important for psychological well-being but does not address the immediate health risks associated with anorexia.
D: Feeling in control of behavior is a valid goal, but weight restoration takes precedence due to the critical nature of the client's physical health in anorexia nervosa.
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.
A nurse is on the hospital quality and performance Improvement committee. The committee is reviewing compliance with prevention measures related to posterior cervical surgical site infections over the first 3 quarters of the year. Which measures should the nurse recognize that indicate the need for improvement compared to benchmarks? Select all that apply.
- A. Glucose control
- B. Intraoperative vancomycin
- C. Post operative normothermia
- D. Perioperative antibiotics
- E. Smoking cessation
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Glucose control, perioperative antibiotics, and smoking cessation are important prevention measures related to posterior cervical surgical site infections. Glucose control is crucial as hyperglycemia can impair immune function, leading to increased infection risk. Perioperative antibiotics help prevent surgical site infections by reducing bacterial load. Smoking cessation is vital as smoking impairs wound healing and increases infection risk. Intraoperative vancomycin (B) is not typically a prevention measure for surgical site infections in posterior cervical surgeries. Postoperative normothermia (C) is important for general patient care but is not specifically related to preventing surgical site infections in this context.