Nokea
A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.
- A. Remind the patient of why breast feeding is the best method of infant feeding.
- B. Request a referral to the lactation consultant.
- C. Determine the patient's knowledge base related to infant feeding options.
- D. Accept the patient's decision without further discussion.
Correct Answer: C
Rationale: Determining the patient’s knowledge base (C) respects her autonomy while ensuring informed decision-making, aligning with patient advocacy. Reminding about breastfeeding (A) or referring to a consultant (B) may pressure the patient, and accepting without discussion (D) neglects education.
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The nurse is caring for assigned clients. The nurse should initially assess the client who
- A. is recovering from a femoral angioplasty and reports their foot is falling asleep.
- B. has diabetes mellitus and refused their prescribed glargine insulin.
- C. received alteplase three hours ago for a stroke and has a Glasgow Coma Scale of 14.
- D. had a T6 spinal cord injury and has not had a bowel movement since yesterday.
Correct Answer: A
Rationale: Numbness post-femoral angioplasty (A) suggests vascular compromise, such as occlusion, requiring immediate assessment. Insulin refusal (B), stable GCS post-alteplase (C), and constipation in spinal injury (D) are less urgent.
The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the licensed practical/vocational nurse (LPN/VN) would require follow-up from the charge nurse?
- A. Obtaining an occult stool sample for a client with ulcerative colitis.
- B. Assessing a newly admitted client with chest pain.
- C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus.
- D. Providing pin care for a client with external fixation of the wrist.
Correct Answer: B
Rationale: Assessing a new client with chest pain (B) requires RN-level judgment due to potential life-threatening conditions, necessitating follow-up if delegated to an LPN. Stool sample collection (A), reinforcing teaching (C), and pin care (D) are within LPN scope.
The nurse is caring for assigned clients. The nurse should initially follow up on the client who
- A. has a basilar skull fracture and has bruises under their eyes.
- B. had a craniotomy and has a change in the Glasgow coma scale (GCS) from 13 to 11 in the last hour.
- C. has amyotrophic lateral sclerosis (ALS) and is requesting to have resuscitation efforts withheld.
- D. has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness.
Correct Answer: B
Rationale: A GCS drop from 13 to 11 post-craniotomy (B) indicates neurological deterioration, possibly from hematoma, requiring immediate follow-up. Bruises with skull fracture (A), ALS DNR request (C), and GBS weakness (D) are less urgent, though GBS needs monitoring.
The nurse is caring for a client experiencing an acute episode of vertigo. Which of the following actions would be a priority for the nurse?
- A. instruct the client to avoid sudden, jerky movements.
- B. Request a prescription for an antihistamine.
- C. Raise the upper side rails of the client's bed.
- D. Assess the client for nausea and vomiting.
Correct Answer: C
Rationale: Raising side rails (C) is the priority in acute vertigo to prevent falls due to dizziness, ensuring immediate safety. Avoiding movements (A), antihistamine (B), and nausea assessment (D) are important but secondary to fall prevention.
The nurse is caring for a client with congestive heart failure. Using the ISBAR format, Select the text that expresses the nurses' recommendation to the physician.
- A. Client reported a cough and shortness of breath while resting.
- B. The onset of symptoms was sudden and not relieved, with the client being positioned with the head of the bed at 90 degrees.
- C. Vital signs were obtained: 156/98; P 108; RR 26/minute; Oxygen saturation 91% on room air.
- D. Lung sounds had crackles in all fields.
- E. A rapid response was called because of the unstable vital signs.
- F. Dr. Thomas Smith was notified to obtain diuretics and critical care monitoring orders.
Correct Answer: B,F
Rationale: Notifying Dr. Smith for diuretics and critical care monitoring (F) is the recommendation in the ISBAR format, proposing specific actions for the physician to address the client’s worsening heart failure. Other options provide situation (A, B), background (C, D), or assessment (E) details.