Nokea
A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
- A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
- B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
- C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
- D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is the client whose blood pressure dropped significantly from 138/86 mm Hg to 106/60 mm Hg. This indicates a potential issue with perfusion and could be a sign of hypovolemic shock, which is a life-threatening condition requiring immediate intervention to prevent further complications. Monitoring and addressing this client's blood pressure is crucial to prevent deterioration.
Choice A is not the priority because pain management can be addressed after ensuring the client's physiological stability.
Choice B indicates a normal progression in wound healing and does not require immediate attention.
Choice C, while showing an increase in blood glucose levels, does not pose an immediate threat to the client's health compared to a significant drop in blood pressure as in Choice D.
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A nurse manager along with members of the nurse practice committee are conducting a skills day for assistive personnel in the medical surgical unit to validate competency. Which skills demonstrated by assistive personnel require immediate follow-up. Select the '3' findings that require immediate follow-up.
- A. AP 1-Quickly pulls fire alarm, then proceeds to remove the client from room. AP 3-Raised bedrails of the bed for client who was reported not alert or oriented, and was sleeping.
- B. AP 2-Verifies with nurse the order in which protective equipment should be removed.
- C. AP 7- While disinfecting portable vital sign monitor wore gloves and washed hand prior to leaving room.
- D. AP 6 - During simulation, which included assisting client into bed, there was no observed handwashing.
- E. AP 5-Following simulation, was unable to identify the locations of alarms on medical surgical unit.
- F. AP 4-Successfully completed skills of simulation including emptying the client's trash can
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Option A requires follow-up because pulling the fire alarm before removing the client may result in leaving the client in a dangerous situation. Option D needs follow-up because not washing hands after assisting a client into bed can lead to the spread of infection. Option E warrants follow-up as not knowing the alarm locations could delay response to emergencies. Options B, C, and F are not immediate concerns as they demonstrate proper procedures or successful completion of tasks.
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 caring for a client who is dying. The nurse should incorporate the principle of nonmaleficence into practice by taking which of the following actions?
- A. Withholding a dose of narcotic pain medication when the client has respiratory depression
- B. Discussing advance directives with the client and the client's family
- C. Providing comfort care measures to the client
- D. Allowing the client's family unlimited visitation at the time of death
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Nonmaleficence is the ethical principle of doing no harm. In this scenario, withholding a dose of narcotic pain medication when the client has respiratory depression aligns with this principle as administering the medication could further compromise the client's respiratory status and potentially harm them. By withholding the medication, the nurse is prioritizing the client's safety and well-being.
Summary of Incorrect Choices:
B: Discussing advance directives is important but does not directly relate to nonmaleficence in this context.
C: Providing comfort care measures is essential but does not specifically demonstrate the principle of nonmaleficence.
D: Allowing unlimited visitation may support emotional well-being but does not directly address the principle of nonmaleficence.
A nurse is preparing to delegate tasks to a licensed practical nurse (LPN). Which of the following tasks is appropriate for the LPN to perform?
- A. Develop a care plan for a client with a new diagnosis of diabetes.
- B. Administer a prescribed subcutaneous insulin injection.
- C. Perform an admission assessment for a client with chest pain.
- D. Evaluate the effectiveness of a client's pain management plan.
Correct Answer: B
Rationale: The correct answer is B: Administer a prescribed subcutaneous insulin injection. LPNs are trained to administer medications, including insulin injections, under the supervision of a registered nurse or physician. LPNs have the knowledge and skills necessary to safely administer medications. Choices A, C, and D involve assessments, evaluations, and care planning, which are tasks typically performed by registered nurses. LPNs can assist with these tasks but should not independently perform them. Overall, LPNs are best suited to carry out tasks related to direct patient care, such as medication administration.
A nurse is delegating client care assignments for the shift. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
- A. Teach a client about low-sodium foods.
- B. Measure and record intake and output for a client.
- C. Perform wound irrigation for a client.
- D. Evaluate pain relief for a client following the administration of a pain medication.
Correct Answer: B
Rationale: The correct answer is B: Measure and record intake and output for a client. This task can be safely delegated to an assistive personnel (AP) as it is a non-invasive and routine task that does not involve critical thinking or interpretation. APs are trained to perform basic tasks like measuring and recording intake and output accurately under the supervision of a nurse. Other choices are incorrect because: A involves providing client education which requires critical thinking and assessment skills, C involves a procedure that requires specific training and skill, and D involves evaluating the effectiveness of pain relief which requires nursing judgment and assessment skills.