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A nurse is working with a social worker and a physical therapist in preparing a discharge projection for a client who is postoperative. Which of the following steps of the nursing process is the nurse engaging in?
- A. Assessment
- B. Planning
- C. Evaluation
- D. Analysis
Correct Answer: B
Rationale: The correct answer is B: Planning. During the planning phase of the nursing process, the nurse collaborates with other healthcare professionals to develop a comprehensive discharge plan for the postoperative client. This involves setting goals, determining interventions, and outlining the necessary resources for a smooth transition from the hospital to home care. Assessment (choice A) involves collecting data, evaluation (choice C) involves determining the effectiveness of the plan, and analysis (choice D) involves breaking down information. In this scenario, the nurse is actively involved in creating a structured plan for the client's discharge, making choice B the correct answer.
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A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
- A. A client who has heart failure and peripheral edema
- B. A client who reports urinary burning and a temperature of 29.2° C (102.51 F)
- C. A client who has cirrhosis of the liver and bruising on their arms
- D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min
Correct Answer: D
Rationale: The correct answer is D because a new onset of atrial fibrillation with a heart rate of 152/min indicates a potentially life-threatening cardiac condition requiring immediate attention to prevent complications such as stroke or heart failure. Atrial fibrillation can lead to decreased cardiac output and increase the risk of blood clots forming in the heart. The high heart rate can also lead to hemodynamic instability. A prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is incorrect as heart failure with peripheral edema, while concerning, does not pose an immediate life-threatening risk compared to a new onset of atrial fibrillation.
Choice B is incorrect as urinary burning and a temperature of 29.2° C (102.51 F) may indicate a urinary tract infection, which is important but not as urgent as the cardiac issue in choice D.
Choice C is incorrect as bruising in a client with cirrhosis of the liver is concerning for potential bleeding disorders, but it is not
A nurse on a medical unit is reviewing the laboratory reports for a client. Which of the following laboratory values is the priority to report to the provider?
- A. Potassium level 3 mEq/L
- B. BUN 9.5 mg/dL
- C. Creatinine 0.4 mg/dL
- D. Sodium 135 mEq/L
Correct Answer: A
Rationale: The correct answer is A: Potassium level 3 mEq/L. A potassium level of 3 mEq/L is below the normal range (3.5-5.0 mEq/L), indicating hypokalemia. Hypokalemia can lead to serious cardiac arrhythmias. Therefore, it is crucial to report this abnormal potassium level promptly to the provider for further evaluation and intervention.
B: BUN 9.5 mg/dL - This is within the normal range (7-20 mg/dL) and does not require immediate intervention.
C: Creatinine 0.4 mg/dL - This is within the normal range (0.6-1.2 mg/dL) and does not indicate an urgent issue.
D: Sodium 135 mEq/L - This is within the normal range (135-145 mEq/L) and does not require immediate action.
A nurse is receiving report on a group of clients. Using the ABCDE priority framework which of the following clients should the nurse see first?
- A. A client who has early dementia and awoke confused to their location this morning
- B. A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning
- C. A client who has pneumonia and has developed wheezing
- D. A client who is postoperative and has a urine output of 50 mL for the past 3 h
Correct Answer: C
Rationale: The correct answer is C because the client with pneumonia developing wheezing is experiencing a potential airway obstruction, impacting their breathing (airway). In the ABCDE priority framework, airway comes first to ensure adequate oxygenation. Choice A may indicate confusion but does not pose an immediate threat to life. Choice B has a fever, but unless there are other concerning symptoms, it does not require immediate attention. Choice D has decreased urine output, indicating a potential issue with circulation or kidneys, but it is not immediately life-threatening. Therefore, C takes precedence due to the potential airway compromise.
A nurse is performing passive range of motion on a client who had a stroke. The nurse should identify that passive range of motion is performed to increase which of the following?
- A. Muscle mass
- B. Bone density
- C. Joint flexibility
- D. Muscle strength
Correct Answer: C
Rationale: Passive range of motion exercises are performed to maintain or improve joint flexibility in clients who are unable to move their joints independently. This helps prevent contractures and stiffness. Joint flexibility allows for better mobility and reduces the risk of injury. The other choices are incorrect because: A) Muscle mass is not directly affected by passive range of motion exercises. B) Bone density is not the primary focus of passive range of motion exercises. D) Muscle strength is not the main goal of passive range of motion exercises.
A nurse is caring for a client who is at risk for a pressure injury. Which of the following actions should the nurse take?
- A. Keep the head of the client’s bed elevated to 45
- B. Provide the client with a high-calorie diet
- C. Massage the client’s bony prominences
- D. Reposition the client every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Provide the client with a high-calorie diet. A high-calorie diet can help promote tissue healing and prevent pressure injuries by providing the necessary nutrients for skin integrity. Keeping the head of the bed elevated to 45 degrees (A) is important for preventing aspiration but not directly related to preventing pressure injuries. Massaging bony prominences (C) can actually increase the risk of pressure injuries by causing friction and shear forces. Repositioning the client every 4 hours (D) is essential but not directly related to the prevention of pressure injuries.