Nokea
It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client?
- A. A business executive admitted with Guillain-Barre syndrome who has residual bilateral numbness in the lower extremities.
- B. A woman who is pregnant with twins and whose due date is one week away.
- C. An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dL (22 mmol/L).
- D. A 2-year-old who contracted Hepatitis A while at a local daycare center.
Correct Answer: C
Rationale: The elderly client with a broken hip and uncontrolled diabetes requires urgent, coordinated care to manage multiple acute conditions.
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The nurse is assisting with a lumbar puncture on a client. During the procedure, a code is called for another client on the unit who is experiencing respiratory arrest. Which action should the nurse take?
- A. Call for an assistant.
- B. Respond to the code.
- C. Close the room door.
- D. Finish the procedure.
Correct Answer: A
Rationale: Calling for an assistant maintains the lumbar puncture's safety while allowing the nurse to address the code promptly.
A 5-year-old boy with mumps is being transferred to the pediatric unit. Which nursing intervention is most important for the nurse to implement?
- A. Place an isolation cart outside of the room to initiate droplet precautions.
- B. Schedule bedside play time with the occupational therapist.
- C. Instruct the child's parents about the need for transmission precautions.
- D. Assign the child to a room close to the nurse's station.
Correct Answer: A
Rationale: Initiating droplet precautions with an isolation cart prevents mumps transmission, a priority for infection control.
When making assignments for residents of a long-term care facility who require assistance with feeding, which client should the charge nurse assign to the practical nurse (PN) rather than the unlicensed assistive personnel (UAP)?
- A. An elderly woman who refuses to eat most meals served.
- B. A disabled client who is learning to use adaptive equipment.
- C. A client who drools but swallows solids after many attempts.
- D. An older, edentulous client who has loose fitting dentures.
Correct Answer: A
Rationale: The client refusing meals requires a PN's assessment to address potential psychological or physiological issues.
The healthcare provider discusses with a male client the need for a cardiac catheterization, describes the risks and benefits of the procedure, and asks the nurse to have the client sign the consent form. When the nurse presents the consent form for signature, the client hesitates and asks the nurse how the wires will keep his heart going. Which action should the nurse take?
- A. Call the client's next of kin and have them provide verbal consent.
- B. Explain the procedure again in detail and clarify any misperceptions.
- C. Notify the healthcare provider of the client's lack of understanding.
- D. Postpone the procedure until the client understands the risks/benefits.
Correct Answer: C
Rationale: Notifying the provider ensures the client's misunderstanding is addressed for valid informed consent.
The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat and sleeps most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?
- A. Maintain in high Fowler's position.
- B. Report any change in urine color.
- C. Keep mucous membranes moist.
- D. Record the client's daily weight.
Correct Answer: C
Rationale: Keeping mucous membranes moist prevents discomfort and complications, a priority in palliative care.