Nokea
An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?
- A. the client complaining of chest pain and nausea who is diaphoretic
- B. the client with a simple fracture of the radius from a fall on a staircase
- C. the client complaining of slight redness and itching at the IV site in his hand
- D. the client presenting with a sprained ankle from a tree branch falling on him
Correct Answer: A
Rationale: Chest pain, nausea, and diaphoresis suggest a potential myocardial infarction, a life-threatening condition requiring immediate attention. Options B, C, and D describe less urgent conditions.
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The school nurse is monitoring the diet of a child with cystic fibrosis. Which type of diet would the family be advised to follow?
- A. low calorie, high fiber
- B. low fiber, low fat
- C. low sodium, gluten free
- D. high fat, high calorie
Correct Answer: D
Rationale: High-fat, high-calorie diets support nutritional needs in cystic fibrosis due to malabsorption.
The charge nurse in the medical unit is preparing a bed assignment for a stable client diagnosed with necrotizing fasciitis. The client has a history of diabetes and hepatitis. There are four beds available. The nurse knows that the best roommate for this client is which of the following?
- A. a client with gout in the large toe
- B. a client with fever, vomiting, and diarrhea
- C. a client with MRSA
- D. a client with severe dementia with a tendency to wander
Correct Answer: A
Rationale: The gout client has a non-infectious condition, minimizing infection risk for the immunocompromised necrotizing fasciitis client.
The nurse is caring for a client who is post-op day 1 for a coronary artery bypass graft (CABG). The nurse knows that continuity of care for this client is ensured by doing which of the following? Select all that apply.
- A. using standardized handoff reports
- B. knowing how to perform a chart check
- C. following up on outstanding lab reports and incomplete orders
- D. knowing the proper procedures to transfer clients to another floor
Correct Answer: A,B,C,D
Rationale: Standardized handoffs, chart checks, following up on labs/orders, and proper transfer procedures all ensure continuity of care.
A charge nurse is preparing client care assignments for the upcoming shift. A client who underwent a laminectomy is scheduled to return from the recovery care unit. Which staff member should receive this client?
- A. graduate nurse with 3 months of experience
- B. RN with 1 year of experience
- C. certified nursing assistant with 5 years of experience
- D. charge nurse with 2 years of experience
Correct Answer: B
Rationale: An RN with 1 year of experience has sufficient skills for post-laminectomy care. A CNA lacks the scope, and a graduate nurse may need more experience.
A nurse is working with an unlicensed assistive personnel (UAP) to perform a bed bath on a client. The nurse notes the smell of alcohol on the UAP's breath. Which is the priority nursing action?
- A. Work closely with the UAP during the shift and observe for any signs of impairment.
- B. Complete the bed bath without comment. The unit is already short one staff member.
- C. Offer chewing gum to the UAP. Since she does not give medications, she can do her job as she does not appear impaired.
- D. Call for another nurse to complete the bath and immediately report the UAP to the charge nurse or unit manager.
Correct Answer: D
Rationale: The smell of alcohol suggests potential impairment, which poses a safety risk to clients. Reporting to the charge nurse ensures client safety and follows protocol. Options A, B, and C fail to address the potential risk adequately.