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After talking to a her family, an elderly client says that she wants to change their living will she wrote two weeks ago. The nurse's most appropriate reply would be:
- A. You can only change your living will a year after it is formulated.
- B. Let me see if I can find someone to help you.
- C. You cannot only make changes to your will after 3 weeks.
- D. Let's call your lawyer first and see what he thinks they think.
Correct Answer: B
Rationale: The nurse should assist the client by finding someone to help (B), such as a social worker or legal resource, to facilitate changes to the living will. There are no time restrictions (A, C), and contacting a lawyer (D) is unnecessary unless requested by the client.
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The nurse is providing care for a patient recently transferred from the post-anesthesia care unit [PACU]. The chart indicates that the patient was medicated for pain 1 hour ago, yet the patient reports that he is experiencing extreme pain. He is not due for further medication until another 2 hours. How might the nurse intervene as a patient advocate?
- A. Contact the physician regarding the need for more effective pain management.
- B. Assist the patient to use non-pharmacological pain management strategies.
- C. Explain to the patient that giving the pain medication too soon can be dangerous.
- D. Provide a quiet environment to help the patient rest and cope with his pain level.
Correct Answer: A
Rationale: Contacting the physician (A) advocates for the patient by addressing uncontrolled pain, potentially adjusting the regimen. Non-pharmacological strategies (B), explaining risks (C), or providing a quiet environment (D) are supportive but do not directly address the need for better pain control.
The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment?
- A. 74-year-old with several heavily bleeding wounds who is lethargic and pale.
- B. 37-year-old who appears anxious, tired, and using neck muscles to breathe.
- C. 16-year-old who is confused, holding her head, and complaining of nausea.
- D. 65-year-old who rates his pain at 10/10 and is guarding his right leg.
Correct Answer: A
Rationale: A 74-year-old with heavy bleeding, lethargy, and pallor (A) indicates hemorrhagic shock, a life-threatening condition requiring immediate treatment. Respiratory distress (B), confusion with nausea (C), and severe pain (D) are serious but less urgent than uncontrolled bleeding.
The nurse is caring for a client with diabetic ketoacidosis and is prescribed a bolus of regular insulin followed by a continuous infusion of regular insulin. Prior to starting the continuous infusion, the nurse administers 1 unit/kg of regular insulin to the client instead of the 0.1 unit/kg bolus. The nurse should take which initial action?
- A. Notify the primary healthcare provider (PHCP)
- B. Complete an incident report
- C. Assess the client for hypoglycemia
- D. Withhold the insulin infusion
Correct Answer: C
Rationale: Administering a 10-fold insulin overdose (C) risks severe hypoglycemia, so assessing the client immediately is critical to detect and treat low glucose. Notifying the PHCP (A), reporting (B), and withholding infusion (D) follow but are less urgent than client assessment.
The nurse is caring for the following assigned clients. The nurse should initially follow-up on the client who
- A. is taking lithium that reports nausea and vomiting.
- B. is refusing their prescribed quetiapine.
- C. is reporting a headache following the first dose of citalopram.
- D. gets drowsy following a dose of alprazolam.
Correct Answer: A
Rationale: Nausea and vomiting with lithium (A) suggest potential toxicity, requiring immediate follow-up. Quetiapine refusal (B), headache with citalopram (C), and drowsiness with alprazolam (D) are less urgent or expected side effects.
The registered nurse (RN) is planning client care assignments. Which client would be appropriate to assign to the licensed practical/vocational nurse (LPN/VN)? A client
- A. with Guillain-Barre syndrome client reporting dyspnea while at rest.
- B. with stage 3 and 4 pressure injuries present in the sacral area.
- C. 2 hours postoperative total laryngectomy.
- D. awaiting a referral for outpatient diabetic support services.
Correct Answer: D
Rationale: A client awaiting a referral for diabetic support services (D) is stable and suitable for LPN care, involving coordination within scope. Guillain-Barré syndrome with dyspnea (A), severe pressure injuries (B), and recent laryngectomy (C) require RN assessment due to critical or complex needs.