Nokea
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
- A. Send the unsigned informed consent form to the facility's risk manager.
- B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.
- C. Ensure that the client's family supports the provider's decision for surgery,
- D. Determine if the procedure is medically necessary for the client.
Correct Answer: B
Rationale: The correct answer is B: Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. This is important because the client is in a coma and unable to provide informed consent. The health care surrogate acts on behalf of the client and must be fully informed about the procedure to make decisions in the client's best interest. Sending the unsigned consent form to the risk manager (A) is not appropriate as it does not address the issue of informed consent. Ensuring family support (C) is important but does not address the legal requirement of informed consent. While determining medical necessity (D) is important, in this case, the primary concern is obtaining informed consent.
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The nurse should first address the client’s-------followed by the client’s-----
- A. safety
- B. abrasions
- C. hygiene
- D. heart rate
- E. pain
- F. BMI
Correct Answer: E,A
Rationale: Addressing pain and safety prioritizes client needs.
A quality control nurse is reviewing medication prescriptions for a group of clients. Which of the following medication prescriptions should the nurse identify as being complete?
- A. Tetracycline 200 mg PO
- B. Epoetin alfa 150 units/kg three times weekly
- C. Digoxin 0.25 mg PD dally
- D. Cimetidine PO twice daily
Correct Answer: C
Rationale: The correct answer is C: Digoxin 0.25 mg PO daily. The rationale for this choice being complete is that it includes the medication name (Digoxin), dose (0.25 mg), route of administration (PO - by mouth), and frequency (daily). This prescription is clear and specific, providing all necessary information for the nurse to accurately administer the medication.
Other choices are incorrect:
A: Missing frequency information.
B: Missing route of administration and frequency.
D: Missing dose and frequency.
For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.
- A. Perform suctioning
- B. Assess for urinary retention.
- C. Assess blood pressure every 15 min
- D. Withhold pain medication for headache until other manifestations resolve.
- E. Place client in supine position
- F. Administer nifedipine.
Correct Answer:
Rationale: Rationales provided within the question context.
Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?
- A. Waits for 2 min between suctions
- B. Encourages the client to cough during suctioning
- C. Applies suction for 15 seconds
- D. Inserts the catheter without applying suction
Correct Answer: C
Rationale: Suctioning longer than 10-15 seconds risks hypoxia.
Which of the following findings require follow-up?
- A. 30-year-old client at 33 weeks gestation, Gravida 4 Para 3
- B. CBC and urinalysis collected and sent to lab.
- C. Maternal blood type: Rh+
- D. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
- E. Client reports lower back pain and pinkish vaginal discharge.
- F. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds,
- G. FHR baseline 145, minimal variability.
Correct Answer: E,F,G
Rationale: The correct answers are E, F, and G because they indicate potential complications during pregnancy.
E: Lower back pain and pinkish vaginal discharge can be signs of preterm labor or placental issues, requiring immediate follow-up.
F: Uterine contractions every 8 minutes, strong palpation, and duration 30 seconds suggest active labor, needing monitoring for progression.
G: Fetal heart rate (FHR) baseline of 145 with minimal variability may indicate fetal distress, necessitating further assessment.
Other choices are routine findings or do not pose immediate risks, such as A (normal obstetric history), B (routine lab tests), C (Rh+ blood type is common), and D (history of preterm birth but no current concerns).