Nokea
A nurse is providing care for a client who has terminal cancer and is refusing chemotherapy. Which of the following actions should the nurse take?
- A. Request the client sign an informed consent.
- B. Encourage the client to reconsider their decision
- C. Communicate the client's decision to the provider.
- D. Provide care for the client using a sympathetic approach.
Correct Answer: C
Rationale: The correct answer is C: Communicate the client's decision to the provider. This is the most appropriate action as it ensures the client's wishes are respected while also involving the healthcare provider in the decision-making process. By communicating the client's decision, the nurse is upholding the client's autonomy and promoting patient-centered care. Option A is incorrect as the client's refusal of chemotherapy does not require informed consent. Option B is inappropriate as it undermines the client's autonomy by pressuring them to reconsider. Option D is not the best choice as it focuses on the nurse's approach rather than facilitating communication between the client and the provider.
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A nurse working in the emergency department is assessing several clients. Which of the following clients is the highest priority?
- A. A client who has a raised red skin rash on his arms, neck, and face
- B. A client who has active bleeding from a puncture wound of the left groin area
- C. A client who reports right-sided flank pain and is diaphoretic
- D. A client who reports shortness of breath and left neck and shoulder pain
Correct Answer: B
Rationale: The correct answer is B, a client with active bleeding from a puncture wound of the left groin area. This is the highest priority because active bleeding can lead to severe blood loss, shock, and death if not controlled promptly. Immediate intervention is needed to stop the bleeding, assess for further injuries, and ensure the client's stability. Choices A, C, and D describe concerning symptoms that require attention but do not pose immediate life-threatening risks like uncontrolled bleeding. Therefore, they are of lower priority. It is crucial for the nurse to prioritize clients based on the severity and urgency of their conditions to provide timely and appropriate care.
A nurse is preparing to transfer a client from the emergency department to a medical-surgical unit using the SBAR communication tool. Which of the following information should the nurse include in the background portion of the report?
- A. A prescribed consultation
- B. The client's vital signs
- C. The client's name
- D. The client's code status
Correct Answer: D
Rationale: The correct answer is D: The client's code status. In the background portion of an SBAR report, the nurse should include the client's code status to inform the receiving unit about the client's preferences for resuscitation in case of an emergency. This information is crucial for providing appropriate and individualized care.
A: A prescribed consultation is typically included in the assessment or recommendations sections of the SBAR report, not the background.
B: The client's vital signs are typically included in the assessment section to provide current physiological data.
C: The client's name is already known and is not necessary in the background portion of the report.
E, F, G: These choices are not applicable to the background portion of the SBAR report.
A triage nurse in an emergency department is caring for a group of clients. Which of the following clients should the nurse assess first?
- A. A client who has a closed femur fracture from a fall
- B. A client who has a superficial burn covering 10% of their total body surface area
- C. A client who is experiencing severe vomiting and diarrhea with tachycardia
- D. A client who is confused and has slurred speech
Correct Answer: D
Rationale: Confusion and slurred speech suggest a possible stroke, a time-sensitive emergency requiring immediate assessment to optimize outcomes.
A nurse is assessing a client who has meningitis. Which of the following findings should the nurse report to the provider immediately?
- A. Decreased level of consciousness
- B. Report of photophobia
- C. Increased temperature
- D. Generalized rash over trunk
Correct Answer: A
Rationale: The correct answer is A. A decreased level of consciousness in a client with meningitis indicates a severe neurological deterioration, possibly due to increased intracranial pressure. Immediate intervention is crucial to prevent further complications like brain damage or herniation. Reporting this to the provider facilitates prompt assessment and treatment. Choices B, C, and D are also common in meningitis but are not immediate concerns. Photophobia and increased temperature are typical symptoms, while a rash may indicate a different condition like viral exanthem.
A nurse on a medical surgical unit is caring for a group of clients with the assistance of a licensed practical nurse (LPN) and assistive personnel. Which of the following tasks should the nurse assign to the LPN?
- A. Providing postmortem care for a client who has just died
- B. Reinforcing dietary teaching with a client who has heart disease
- C. Accompanying a client who just had a wound debridement to physical therapy
- D. Obtaining a urine specimen from an older adult client
Correct Answer: D
Rationale: The correct answer is D, assigning the task of obtaining a urine specimen from an older adult client to the LPN. This task falls within the scope of practice for an LPN as it involves basic nursing skills and does not require critical thinking or assessment. LPNs are trained to perform routine procedures such as specimen collection under the supervision of a registered nurse. Providing postmortem care (A) requires emotional support and specialized knowledge beyond the LPN's scope. Reinforcing dietary teaching (B) and accompanying a client to physical therapy (C) involve critical thinking and assessment skills that are typically within the RN's scope. Therefore, D is the correct choice.