Nokea
A nurse is triaging clients in the emergency department. Which of the following clients should the nurse ask the provider to care for first?
- A. A toddler who has asthma and has a pulse oximetry reading of 95% while receiving oxygen at 2 L/min
- B. An adolescent who has sickle cell disease, reports pain as 7 on a scale of 0 to 10, and requests pain medication
- C. A toddler who has otitis media, a temperature of 39.2 C (102.6° F), and purulent ear discharge
- D. A school-age child who has acute epiglottitis, is drooling, and has an absence of spontaneous cough
Correct Answer: D
Rationale: The correct answer is D. Acute epiglottitis is a medical emergency due to potential airway compromise. The child's drooling and absence of cough indicate a severe obstruction that can rapidly progress to complete airway closure. Immediate intervention is crucial to prevent respiratory distress or arrest. Choices A, B, and C have less urgent conditions that can be managed after ensuring the child with epiglottitis receives prompt care. Choice A, although having asthma, is stable with adequate oxygenation. Choice B, although in pain, can wait briefly for pain medication. Choice C, although having otitis media, does not present immediate life-threatening risk compared to epiglottitis.
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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 because a significant drop in blood pressure from 138/86 mm Hg at 0800 to 106/60 mm Hg at 1200 indicates potential hypotension, which could be a sign of hemorrhage or shock postoperatively. Hypotension can lead to inadequate tissue perfusion and organ damage. Monitoring and addressing the client's blood pressure promptly is crucial to prevent further complications.
Choice A is not the priority because an increase in pain from 4 to 6 is significant but does not indicate as immediate risk as hypotension. Choice B, a change in wound drainage consistency, may require monitoring but is not as urgent as addressing hypotension. Choice C, an increase in post-meal blood glucose, is important but does not pose an immediate threat to the client's life compared to hypotension in Choice D.
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?
- A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
- B. A client who has terminal cancer and needs assistance with pain management
- C. A client who has dementia and needs help with activities of daily living
- D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
Correct Answer: B
Rationale: The correct answer is B because hospice care is appropriate for clients with terminal illnesses who require palliative care, such as pain management. This client's terminal cancer indicates a need for hospice services to provide comfort and support during end-of-life care. Choices A, C, and D do not meet the criteria for hospice care as they do not involve terminal illness requiring palliative care. Choice A's issue can be managed with assistance, choice C's issue is related to dementia care, and choice D's issue is related to post-stroke care.
A charge nurse allows two nurses who are arguing about who gets to go to lunch first to go together. The charge nurse agrees to take care of both of the nurses' clients while they are at lunch. The charge nurse is demonstrating which of the following types of conflict management?
- A. Cooperating
- B. Compromising
- C. Avoiding
- D. Competing
Correct Answer: A
Rationale: The correct answer is A: Cooperating. The charge nurse is demonstrating cooperation by taking on the responsibility of caring for both nurses' clients while they go to lunch together. This approach shows a willingness to collaborate and find a solution that benefits all parties involved. By cooperating, the charge nurse is promoting teamwork and fostering a positive work environment.
Summary of other choices:
B: Compromising - This would involve finding a middle ground or making concessions, which is not the case in this scenario.
C: Avoiding - This would involve ignoring the conflict or avoiding confrontation, which is not what the charge nurse is doing.
D: Competing - This would involve a win-lose mindset where one party wins at the expense of the other, which is not evident in this situation.
A nurse is participating in a disaster drill for a chemical spill. Which of the following actions should the nurse take first when caring for exposed clients?
- A. Administer antidotes for the chemical agent.
- B. Decontaminate clients by removing contaminated clothing.
- C. Assess clients for respiratory distress.
- D. Document the number of affected clients.
Correct Answer: B
Rationale: Decontaminating clients by removing contaminated clothing is the first step to prevent further exposure and harm, aligning with disaster response protocols for chemical spills.
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.