Nokea
A nurse is documenting notes in the client's electronic record after making rounds on assigned clients. Which entry is an appropriate documentation?
- A. Client appears to be sleeping. Eyes closed
- B. Client reports, 'I'm in pain.' Medication provided
- C. Inspiratory wheezes heard in bilateral lower lung fields
- D. Voided x1
Correct Answer: C
Rationale: Inspiratory wheezes in bilateral lower lung fields is a specific, objective finding that accurately describes the client's condition. The other entries are vague, lack detail, or are subjective without supporting data.
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After returning from the postanesthesia care unit, a man who had abdominal surgery is ordered to be in semi-sitting position. What is the primary reason for this position for this client?
- A. To prevent venous stasis
- B. To promote circulation
- C. To reduce tension on the incision
- D. To prevent respiratory distress
Correct Answer: D
Rationale: Semi-sitting position promotes lung expansion, preventing respiratory distress post-abdominal surgery. It has secondary benefits for circulation and incision tension.
A health care provider is screaming at the nurse in the hallway. 'Why didn't you get that surgery scheduled sooner?' What is the best response by the nurse?
- A. I am so sorry; I will get this fixed and schedule the surgery immediately
- B. I am uncomfortable with your tone, please excuse me while I locate my supervisor
- C. I delegated this task to the unlicensed assistive personnel: please follow up with them.
- D. I think you are overreacting, you should have specified the day and time
Correct Answer: B
Rationale: Responding calmly and redirecting to a supervisor de-escalates the situation professionally while addressing the inappropriate tone. Accusing the provider of overreacting is confrontational and unprofessional.
Which of the following are correct nursing actions related to client positioning? Select all that apply.
- A. Position client in Fowler position after cardiac catheterization via femoral entry
- B. Position client in Trendelenburg position on the left side if air embolism is suspected
- C. Position client on the left side following a liver biopsy
- D. Position client on the side with head, back, and knees flexed during lumbar puncture
- E. Position client with the arm raised above the head for chest tube placement
Correct Answer: B,D,E
Rationale: Trendelenburg on the left traps air in the heart’s apex for air embolism, side-lying with flexion aids lumbar puncture access, and arm elevation facilitates chest tube placement. Fowler post-catheterization risks bleeding, and right side-lying is standard post-liver biopsy.
The nurse is assisting in developing the plan of care for a client diagnosed with anorexia nervosa who is being admitted after unsuccessful outpatient treatment. The nurse understands that which client outcome is the priority?
- A. Acknowledges poor interpersonal skills
- B. Identifies new coping mechanisms
- C. Increases caloric intake to gain weight
- D. Verbalizes sources of conflict and anger
Correct Answer: C
Rationale: In anorexia nervosa, severe malnutrition poses immediate health risks, making increased caloric intake and weight gain the priority to stabilize physical health. Addressing interpersonal skills, coping mechanisms, or emotional conflicts is secondary until nutritional status improves.
Which of the following individuals may legally give informed consent?
- A. an 86-year-old male with advanced Alzheimer's disease
- B. a 14-year-old girl needing an appendectomy who is not an emancipated minor
- C. a 72-year-old female scheduled for a heart transplant
- D. a 6-month-old baby needing bowel surgery
Correct Answer: C
Rationale: The 72-year-old female, presumed competent, can give informed consent. Those with advanced Alzheimer's, non-emancipated minors, and infants cannot legally consent. Coordinated Care