Nokea
A student nurse is caring for a client who will be receiving sodium nitroprusside (Nipride) via IV infusion. What action by the student causes the registered nurse to intervene?
- A. Assessing the IV site before giving the drug.
- B. Obtaining a pump compatible with the IV site.
- C. Removing the IV bag from the brown plastic cover.
- D. Taking and recording a baseline set of vital signs.
Correct Answer: C
Rationale: Nitroprusside degrades in the presence of light, so it must be protected by leaving it in the original brown plastic bag when infusing. The other actions are correct and appropriate.
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A nurse assesses a client in the emergency department. Unlicensed assistive personnel (UAP) reports the vital signs and the nurse sees they are only slightly different from previous readings. What action does the nurse delegate next to the UAP?
- A. Assess the client for pain or discomfort.
- B. Measure urine output from the catheter.
- C. Reposition the client to the unaffected side.
- D. Keep with the client and reassure him or her.
Correct Answer: B
Rationale: Urine output changes are a sensitive early indicator of shock. The nurse should delegate emptying the urinary catheter and measuring output to the UAP as a baseline for hourly urine output measurements. The UAP cannot assess for pain. Repositioning may or may not be effective for decreasing restlessness. Reassuring the client is a therapeutic nursing action but not the priority in this situation.
A client is in the early stages of shock and is restless. What comfort measures does the nurse delegate to the nursing student? (Select all that apply.)
- A. Bringing the client warm blankets.
- B. Providing the client with hot tea.
- C. Massaging the client's painful legs.
- D. Reorienting the client as needed.
- E. Sitting with the client for reassurance.
Correct Answer: A,D,E
Rationale: The nurse can delegate bringing warm blankets, reorienting the client to decrease anxiety, and sitting with the client for reassurance. Providing hot tea is inappropriate as the client should be NPO. Massaging the legs is not recommended due to the risk of dislodging clots, which could lead to pulmonary embolism.
A client has been brought to the emergency department after being shot multiple times. What action should the nurse perform first?
- A. Apply personal protective equipment.
- B. Notify local law enforcement officials.
- C. Obtain universal donor blood.
- D. Prepare the client for emergency surgery.
Correct Answer: A
Rationale: The nurse's priority is to care for the client. Since the client has gunshot wounds and is bleeding, the nurse applies personal protective equipment (e.g., gloves) prior to care to ensure safety. This takes priority over notifying law enforcement or preparing for surgery. Requesting blood can be delegated.
A client arrives in the emergency department after being in a car crash with fatalities. The client has a nearly amputated leg and is bleeding profusely. What action by the nurse takes priority?
- A. Apply direct pressure to the bleeding.
- B. Ensure the client has a patent airway.
- C. Obtain consent for emergency surgery.
- D. Start two large-bore IV catheters.
Correct Answer: B
Rationale: Airway is the priority in emergency care, followed by breathing and circulation (IVs and direct pressure). Ensuring a patent airway is critical before addressing bleeding or other interventions. Obtaining consent is typically done by the physician.
A nurse caring for a client notes the following assessments: white blood cell count 3800/mm³, temperature 96.8°F, and weak pedal pulses. What action by the nurse takes priority?
- A. Document the findings in the client's chart.
- B. Give the client warmed blankets for comfort.
- C. Notify the health care provider immediately.
- D. Prepare to administer insulin per sliding scale.
Correct Answer: C
Rationale: This client has several indicators of sepsis with systemic inflammatory response, such as low white blood cell count, hypothermia, and poor perfusion (weak pulses). The nurse should notify the health care provider immediately to initiate prompt treatment. Documentation and comfort measures are important but not the priority. Insulin may not be needed in this scenario.