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A nurse is triaging a group of clients following a disaster. Which of the following clients should the nurse recommend for treatment first?
- A. A client who has a neck injury and is unable to breathe spontaneously
- B. A client who has bipolar disorder and is exhibiting signs of hallucination
- C. A client who has two open chest wounds with a left tracheal deviation
- D. A client who has major burns over 75% of her body surface area
Correct Answer: A
Rationale: A neck injury causing inability to breathe spontaneously is an immediate airway threat, prioritizing it per the ABCs of basic life support.
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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 is preparing a client for surgery. The client expresses concern that someone might steal her purse during the procedure. Which of the following actions should the nurse take?
- A. Offer to store the purse at the nurses' station.
- B. Tell the client to leave her purse in a drawer of the bedside table.
- C. Place the purse in the clothing bag with the client's other belongings.
- D. Offer to place the purse in the facility safe.
Correct Answer: D
Rationale: The correct answer is D: Offer to place the purse in the facility safe. This is the best option as it ensures the client's belongings are kept secure during the surgery. Storing the purse at the nurses' station (A) may not guarantee its safety. Leaving the purse in a drawer (B) or clothing bag (C) can also pose a risk of theft. Placing it in the facility safe (D) is the most secure and professional solution to address the client's concern.
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.
A facility provides annual staff education regarding ethical practice. A charge nurse recognizes a need for further education when which of the following behaviors is observed?
- A. A nurse informs a confused client who wants to go home that he is going to stay at the facility until he is better.
- B. A nurse gives prescribed opioids to a client who has a terminal illness and respirations of 8/min.
- C. A nurse explains to a client's family that a DNR order includes withholding comfort measures.
- D. A nurse refuses to actively participate during an elective abortion procedure scheduled for her client.
Correct Answer: C
Rationale: The correct answer is C. This is the only behavior that goes against ethical practice in this scenario. The charge nurse should recognize the need for further education when a nurse incorrectly explains that a DNR order includes withholding comfort measures, as this is inaccurate information. Justification for other choices: A is incorrect because it shows compassionate care. B is incorrect because it demonstrates appropriate pain management for a terminally ill client. D is incorrect because nurses have the right to refuse participation in procedures that go against their beliefs.
A nurse is caring for a client who has uterine prolapse. The provider has recommended a total abdominal hysterectomy, but the client tells the nurse that the surgery is not an option. Which of the following is an appropriate action for the nurse to take?
- A. Discuss with the client her concerns regarding the procedure.
- B. Initiate a mental health consult to determine the client's reasons for refusing surgery.
- C. Provide the client with information on treatment options and outcomes.
- D. Inform the client of the consequences of uterine prolapse and the need for intervention.
Correct Answer: A
Rationale: Correct Answer: A: Discuss with the client her concerns regarding the procedure.
Rationale:
1. Building Trust: By discussing the client's concerns, the nurse shows empathy and builds trust.
2. Client Autonomy: Respecting the client's decision-making process is essential.
3. Informed Decision-Making: Understanding the client's fears helps in providing tailored information.
4. Collaboration: Discussing concerns opens the door for shared decision-making.
5. Holistic Care: Addressing emotional aspects is crucial for overall well-being.
Incorrect Choices:
- B: Initiating a mental health consult may be premature and could undermine the client's autonomy.
- C: Providing information without addressing concerns may not address the root of the refusal.
- D: Informing the client without understanding her perspective may lead to increased anxiety and resistance.