Nokea
During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube. The nurse should initially
- A. obtain a specimen for culture.
- B. assess the drainage.
- C. place a sterile dressing around the gastrostomy tube.
- D. assess the client's temperature for fever.
Correct Answer: B
Rationale: Assessing the drainage (B) is the first step to determine the cause, such as infection or tube malfunction, guiding further action. Obtaining a culture (A), applying a dressing (C), or checking for fever (D) are secondary without initial assessment data.
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The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?
- A. Risk for infection
- B. Risk for disturbed sensory perception
- C. Risk for disturbed body image
- D. Risk for ineffective tissue perfusion
Correct Answer: B
Rationale: Risk for disturbed sensory perception (B) is the priority in Bell’s palsy due to facial paralysis, which can lead to corneal abrasion or oral injury. Infection (A), body image (C), and perfusion (D) are secondary concerns.
The nurse in the emergency department (ED) is triaging clients. The nurse should immediately follow up on the client who
- A. is being treated for depression and is requesting a refill of the prescribed antidepressant.
- B. is receiving external-beam radiation for breast cancer and reports blistering at the site.
- C. fell while riding their bicycle and has bruising and abrasions to the right upper extremities.
- D. reports left testicular pain and swelling with nausea and vomiting.
Correct Answer: D
Rationale: Testicular pain/swelling with nausea (D) suggests testicular torsion, an emergency requiring immediate follow-up to prevent organ loss. Depression refill (A), radiation blisters (B), and abrasions (C) are less urgent.
The nurse in the emergency department (ED) is caring for an unconscious client who sustained a head injury following a motor vehicle crash. The health care provider (HCP) has ordered an emergency surgery. Which action should the nurse take regarding informed consent?
- A. obtain a court order for the surgical procedure in place of an informed consent
- B. search the client's belongings for any identification
- C. transport the client to the operating room for surgery immediately
- D. call the police to report the incident, identify the client, and locate the family
Correct Answer: C
Rationale: For an unconscious client requiring emergency surgery, implied consent applies, allowing immediate transport to the operating room (C) to save life or prevent harm. Court orders (A), searching belongings (B), or calling police (D) delay critical care and are not required for emergency consent.
The nurse is triaging a group of pediatric clients. The nurse should first see the client who is
- A. reporting pain 5/10 on the Numerical Rating Scale after burning their right forearm.
- B. drooling and experiencing difficulty with swallowing.
- C. experiencing a temperature of 101.1°F (38.4°C) and a headache.
- D. reporting excessive thirst and has a thready peripheral pulse.
Correct Answer: B
Rationale: Drooling and difficulty swallowing (B) suggest airway obstruction, such as epiglottitis, a life-threatening emergency. Burns (A), fever with headache (C), and thirst with thready pulse (D) are concerning but less immediately critical.
The nurse is caring for a client recovering from hip surgery who needs to regain strength to climb the flight of stairs leading to their bedroom at home. The nurse should recommend a referral to a
- A. physical therapist (PT).
- B. nutritionist.
- C. C. case manager.
- D. D. occupational therapist (OT).
Correct Answer: A
Rationale: A physical therapist (A) specializes in improving strength and mobility, essential for stair climbing post-hip surgery. Nutritionists (B) focus on diet, case managers (C) coordinate care, and occupational therapists (D) address daily living activities.