Nokea
For each assessment finding, click to specify if the finding is an indication of physical maltreatment, neglect, or financial maltreatment.
- A. Client reports having little food in the house.
- B. Client has bruises in various stages of healing.
- C. Client wears dirty clothing
- D. Client has no access to bank accounts
Correct Answer: A,B,C,D
Rationale: These findings suggest multiple forms of maltreatment.
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A nurse has just received change-of-shift report for four clients. Which of the following clients should the nurse assess first?
- A. A client who is scheduled for a procedure in 1 hr
- B. A client who received a pain medication 30 min ago for postoperative pain
- C. A client who was just given a glass of orange juice far a low blood glucose level
- D. A client who has 100 mL of fluid remaining in his IV bag
Correct Answer: C
Rationale: The correct answer is C. The nurse should assess the client who just drank orange juice for a low blood glucose level first because hypoglycemia can lead to serious complications like seizures or loss of consciousness. Assessing and addressing the client's blood glucose level promptly is crucial to prevent harm.
Choice A is not the priority as the client scheduled for a procedure in 1 hour can wait for assessment until after the client with low blood glucose is evaluated.
Choice B, the client who received pain medication 30 minutes ago, can be assessed after the client with low blood glucose since the medication's effects have likely already taken place.
Choice D, the client with 100 mL of fluid remaining in the IV bag, can also wait for assessment as it does not pose an immediate threat to the client's health compared to low blood glucose.
Therefore, prioritizing the assessment of the client with low blood glucose is crucial to ensure their safety and well-being.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
- A. Send the unsigned informed consent form to the facility's risk manager.
- B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.
- C. Ensure that the client's family supports the provider's decision for surgery,
- D. Determine if the procedure is medically necessary for the client.
Correct Answer: B
Rationale: The correct answer is B: Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. This is important because the client is in a coma and unable to provide informed consent. The health care surrogate acts on behalf of the client and must be fully informed about the procedure to make decisions in the client's best interest. Sending the unsigned consent form to the risk manager (A) is not appropriate as it does not address the issue of informed consent. Ensuring family support (C) is important but does not address the legal requirement of informed consent. While determining medical necessity (D) is important, in this case, the primary concern is obtaining informed consent.
A nurse is caring for a client whose partner recently died. The nurse sits with the client to provide comfort. Which of the following ethical principles is the nurse demonstrating?
- A. Fidelity
- B. Veracity
- C. Autonomy
- D. Beneficence
Correct Answer: D
Rationale: The correct answer is D: Beneficence. Beneficence is the ethical principle that involves doing good and promoting the well-being of others. By sitting with the client to provide comfort after the loss of their partner, the nurse is demonstrating beneficence by showing compassion and support. Fidelity (A) relates to keeping promises and being faithful to commitments. Veracity (B) is about truthfulness and honesty. Autonomy (C) refers to respecting the client's right to make their own decisions. The other choices are not directly related to the nurse's action of providing comfort in this context.
A nurse is caring for a client who is immobile. Which of the following interventions is appropriate to prevent contracture?
- A. Position a pillow under the client's knees.
- B. Place a towel roll under the client's neck.
- C. Align a trochanter wedge between the client's legs
- D. Apply, an orthotic to the client's foot
Correct Answer: D
Rationale: The correct answer is D: Apply an orthotic to the client's foot. This intervention helps to maintain proper alignment of the foot, preventing contractures that can occur due to prolonged immobility. Placing a pillow under the client's knees (choice A) is beneficial for reducing pressure on the lower back but does not specifically address foot contractures. Similarly, placing a towel roll under the client's neck (choice B) is helpful for neck support but does not prevent foot contractures. Aligning a trochanter wedge between the client's legs (choice C) is aimed at hip alignment and not foot contractures. Therefore, the most appropriate intervention to prevent foot contractures in an immobile client is applying an orthotic to the client's foot.
For each potential provider prescription click to specify if the prescription is anticipated or contraindicated for the client.
- A. Administer famotidine 20 mg via intermittent IV infusion twice daily.
- B. insert an indwelling urinary catheter.
- C. Administer lactated Ringer's 1L via IV bolus.
- D. Insert a nasogastric tube and maintain low intermittent suction.
Correct Answer: A,C,D
Rationale: [Explanation: The correct answer is - A,C,D. Administering famotidine helps reduce stomach acid, beneficial for clients with gastric issues. Lactated Ringer's IV bolus helps with fluid resuscitation. Inserting a nasogastric tube can help with decompression or feeding. Inserting an indwelling urinary catheter is not typically provider-initiated unless medically necessary. Therefore, A, C, and D are anticipated for client care, while B is contraindicated unless specifically indicated.]