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An adult client is admitted via the Emergency Department with a head injury that will initially require intensive care. Which role is responsible for coordinating the progression of this client's care through rehabilitation and discharge?
- A. Nurse case manager.
- B. Adult nurse practitioner.
- C. Neurology unit supervisor.
- D. Risk management nurse.
Correct Answer: A
Rationale: The nurse case manager coordinates the client's care continuum, collaborating with teams from admission to discharge. Other roles focus on specific care aspects, not overall coordination.
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A male client who fell at home and experienced a brief loss of consciousness becomes increasingly confused after admission to the medical unit. The family requests an update on the client's condition. Using the SBAR (Situation, Background, Assessment, Recommendation) communication, which information should the nurse provide first?
- A. Increasing confusion of the client.
- B. Client's healthcare power of attorney.
- C. Currently prescribed medications.
- D. Fall at home as reason for admission.
Correct Answer: A
Rationale: The current situation (increasing confusion) is the first step in SBAR, addressing the family's immediate concern. Power of attorney, medications, and fall history are provided later in the communication.
The charge nurse of a critical care unit must transfer a client to a general unit to make a bed available for an incoming trauma client. Based on the information provided, which client is best for the nurse to recommend for transfer to the general unit?
- A. Subtotal thyroidectomy performed one hour ago, receiving a unit of packed red blood cells.
- B. Combined partial and full-thickness burns on the anterior chest three days ago. O2 saturation is 92%.
- C. Renal transplant yesterday, complaining of flank pain and who states, 'it's hot in here.'
- D. Nephrotic syndrome diagnosed 2 days ago, decreased serum protein level and mild edema.
Correct Answer: D
Rationale: The client with nephrotic syndrome is relatively stable, requiring routine care suitable for a general unit. The other clients have acute, unstable conditions requiring critical care monitoring.
The home health aide caring for a home bound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Teach the client about foods high in fiber.
- C. Administer a prescribed dose of a laxative.
- D. Assist the client in drinking warm prune juice.
Correct Answer: D
Rationale: Assisting with drinking warm prune juice is within the aide's scope and promotes natural relief of constipation. Listening for bowel sounds, teaching about fiber, and administering laxatives require nursing skills and are beyond the aide's role.
A postoperative client's respiratory rate decreased from 14 breaths/minute to 6 breaths/minute after administration of an opioid analgesic. Thirty minutes later, the client's respiratory rate decreases to 4 breaths/minute, and the nurse caring for the client notifies the healthcare provider and administers a dose of intravenous (IV) naloxone. The charge nurse should counsel the nurse regarding which intervention?
- A. The initial administration of the analgesic.
- B. The decision regarding when to call the healthcare provider.
- C. The documentation of the client's respiratory rate.
- D. The administration of naloxone via IV.
Correct Answer: B
Rationale: The nurse should have notified the provider at a respiratory rate of 6 breaths/minute, as this indicates opioid-induced respiratory depression. Delaying until 4 breaths/minute risked client safety. Other interventions were appropriate.
Which client requires the most immediate intervention by the nurse?
- A. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6°F (38.1°C).
- B. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: B
Rationale: The client with acute kidney injury and unresponsiveness likely has uremic encephalopathy, a life-threatening condition requiring immediate intervention. The other clients' conditions are less urgent as they are receiving appropriate treatments.