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Someone sees a nursing assistant yell at an elderly client and throw his lunch tray off the table. The nursing assistant could likely be charged with
- A. negligence.
- B. assault.
- C. malpractice.
- D. battery.
Correct Answer: B
Rationale: Yelling and throwing a tray constitute assault (threatening behavior causing fear of harm). Battery involves physical contact, negligence involves failure to act, and malpractice applies to professional errors.
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The nurse has rounded on all the assigned clients. While rounding, several health care providers have written orders on the nurse's clients. Which order would be the priority for the nurse to address?
- A. furosemide (Lasix) 80 mg IV push STAT for a client with fluid overload
- B. a new insulin sliding scale for a client with a glucose level of 242
- C. perform a dressing change on a client with a stage 2 diabetic foot ulcer
- D. discharge a client who was admitted for removal of an abdominal abscess
Correct Answer: A
Rationale: STAT orders for furosemide address acute fluid overload, a potentially life-threatening condition, making it the priority over insulin, dressing changes, or discharge.
A client prescribed furosemide (Lasix) should choose which meal for lunch?
- A. chicken breast, white rice, apple
- B. turkey sandwich on wheat bread, celery sticks, grapefruit
- C. egg salad, cooked carrots, strawberries
- D. baked salmon, spinach salad, banana
Correct Answer: D
Rationale: Furosemide causes potassium loss. A meal with potassium-rich foods (e.g., spinach, banana) helps maintain electrolyte balance.
A client has a diagnosis of discoid lupus erythematosus (DLE). The nurse recognizes that discoid lupus differs from systemic lupus erythematosus because it:
- A. Produces changes in the kidneys
- B. Is confined to changes in the skin
- C. Results in damage to the heart and lungs
- D. Affects both joints and muscles
Correct Answer: B
Rationale: Discoid lupus erythematosus primarily affects the skin, causing chronic rashes, unlike systemic lupus, which can involve multiple organs.
A 72-year-old client with Parkinson disease is recovering from pneumonia and is to be discharged, but he remains weak and has poor control of his hands because of tremors. A home health aide will visit three times weekly to assist the client to bathe, and his daughter will visit every evening after work to help with laundry and housework. Which of the following referrals is most indicated to allow the client to remain independent in his home?
- A. Home meal delivery program (Meals on Wheels)
- B. Friendly Visitors program
- C. Hospice
- D. Occupational therapist
Correct Answer: D
Rationale: An occupational therapist (D) can help with adaptive strategies for tremors, promoting independence. Meal delivery (A), visitors (B), and hospice (C) are less relevant.
The nurse receives an order for blood cultures and sensitivity for a client. Which statement is correct concerning this test?
- A. Preliminary test results are available 36 hours to allow the organisms time to grow.
- B. Growth and identification of the organism often takes 48 to 72 hours to complete.
- C. If the client has IV antibiotics infusing, stop the infusion before drawing blood cultures.
- D. If catheter sepsis is suspected, culturing the catheter tip is more accurate for identification.
Correct Answer: B
Rationale: Blood culture results typically take 48–72 hours for organism identification. Stopping antibiotics or culturing catheter tips is not standard practice.