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A nurse is caring for four clients on a medical-surgical unit. Which of the following clients should the nurse assess first?
- A. A client who has COPD and the capillary refill time on both hands is 4 seconds
- B. A client who has late-stage cirrhosis and whose breath has a fruity odor
- C. A client who has a nasogastric tube for decompression and the gastric aspirate is green with a pH of 5.3
- D. A client who had an indwelling urinary catheter removed 5 hr ago and has not voided
Correct Answer: D
Rationale: The correct answer is D. The nurse should assess the client who had an indwelling urinary catheter removed 5 hours ago and has not voided first. This situation raises concerns about urinary retention, which can lead to bladder distension, discomfort, and potential complications like urinary tract infections. Prompt assessment and intervention are necessary to prevent further issues.
Choice A is incorrect because a capillary refill time of 4 seconds in a client with COPD may suggest impaired circulation but is not as urgent as urinary retention. Choice B is incorrect as fruity odor in late-stage cirrhosis may indicate hepatic encephalopathy but is not an immediate priority. Choice C is incorrect as green gastric aspirate with a pH of 5.3 may indicate bile reflux but not as urgent as urinary retention.
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A nurse is planning care for four clients and is assigning tasks to a licensed practical nurse (LPN) and an assistive personnel (AP). Which of the following should the nurse assign to the LPN?
- A. Measure 1&O for a client who has an indwelling urinary catheter.
- B. Reinforce teaching to a client to begin taking enoxaparin at home following a hip arthroplasty.
- C. Develop a plan of care for a client who has cholecystitis.
- D. Complete an admission assessment for a client who has COPD.
Correct Answer: B
Rationale: The correct answer is B because reinforcing teaching to a client about medication administration falls within the scope of practice for an LPN. LPNs are trained to provide education on medication administration and can reinforce teaching provided by the nurse.
Choice A is incorrect because measuring intake and output for a client with an indwelling urinary catheter requires specific nursing assessment skills that LPNs may not have.
Choice C is incorrect because developing a plan of care for a client with cholecystitis involves critical thinking and decision-making skills typically performed by a registered nurse.
Choice D is incorrect as completing an admission assessment for a client with COPD requires comprehensive assessment skills that are typically within the scope of practice for a registered nurse.
Therefore, choice B is the most appropriate task to assign to an LPN in this scenario.
A nurse is conducting a performance evaluation for an assistive personnel (AP). Which of the following actions by the AP should the nurse identify as requiring further training?
- A. The AP checks a client's identification band before providing a meal tray.
- B. The AP reports a client's complaint of pain to the nurse immediately.
- C. The AP uses an alcohol-based hand rub after assisting a client with ambulation.
- D. The AP leaves a client's bed in the lowest position without raising side rails for a client at risk for falls.
Correct Answer: D
Rationale: The correct answer is D. Leaving a client's bed in the lowest position without raising side rails for a client at risk for falls is a safety violation. The nurse should identify this action for further training because it puts the client at risk of injury. Lowering the bed and raising side rails are essential fall prevention measures. Checking the client's identification band (A) ensures correct client identification. Reporting client complaints of pain (B) promptly is important for timely intervention. Using hand rub after assisting a client (C) promotes infection control. Options E, F, and G are not provided in the question. In summary, choice D is correct as it pertains to client safety, while the other options demonstrate appropriate nursing actions.
A nurse is caring for a client who has a history of dementia. The client is alert and oriented to person, place, and time, and has advance directives. The client is scheduled for a procedure that requires informed consent. Which of the following persons should sign the informed consent?
- A. The client
- B. The client's son, who has a durable power of attorney
- C. The client's partner
- D. The client's daughter, who is the primary caregiver
Correct Answer: A
Rationale: The correct answer is A: The client. Informed consent must be given by the client themselves, as they are alert, oriented, and have advance directives. This ensures that the client fully understands the procedure, risks, benefits, and alternatives before giving consent. The client's autonomy and right to make decisions about their own healthcare are paramount. The other choices are incorrect because only the client themselves can provide informed consent in this scenario. The son with durable power of attorney may make decisions when the client is unable to, but since the client is alert and oriented, they should sign the consent. The partner and daughter do not have the authority to provide informed consent on behalf of the client.
A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?
- A. Dilated pupils
- B. Euphoria
- C. Rhinorrhea
- D. Hallucinations
Correct Answer: B
Rationale: The correct answer is B: Euphoria. Opioid medications can cause euphoria as they act on the brain's reward system, leading to feelings of pleasure and well-being. This can contribute to their potential for misuse and diversion. Dilated pupils (A) are a common side effect of opioid use, not an adverse effect. Rhinorrhea (C) refers to a runny nose and is not typically associated with opioid use. Hallucinations (D) are rare but possible with high doses or in susceptible individuals. In summary, euphoria is a known adverse effect of opioid medications, making it the correct choice.
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.