Nokea
The charge nurse is making assignments for a 15-bed skilled nursing unit with the staff of one nurse, two practical nurses (PN), and two unlicensed assistive personnel (UAP). Which client should be assigned to the PN?
- A. The client who had bilateral above-knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin intravenously.
- B. The client who is in end-stage Alzheimer's, who requires feeding, and is waiting for a long-term facility placement.
- C. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.
- D. The client who has right hemiplegia as the result of a cerebral vascular accident and receives continuous gastrostomy feedings per enteral pump.
Correct Answer: C
Rationale: The pneumonia client with oral medication is stable and within the PN's scope.
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Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Heparin in Normal Saline prescribed for deep vein thrombosis.
- B. Regular Insulin in Normal Saline prescribed for ketoacidosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
Correct Answer: D
Rationale: Ceftriaxone can be safely administered via gravity drip over 30 minutes, unlike high-alert medications like heparin, insulin, or magnesium.
A client is admitted with shortness of breath and hemoptysis. After several tests, the healthcare provider informs the client that the medical diagnosis is stage 4 breast cancer. The client tells the nurse about the decision not to inform the family about the diagnosis. Which intervention should the nurse implement?
- A. Explain that the family has a right to know of potential health problems.
- B. Advise the client to weigh all possible outcomes prior to the decision.
- C. Suggest to the family the value of genetic screening.
- D. Notify the health department of the client's condition.
Correct Answer: B
Rationale: Advising the client to weigh outcomes supports their autonomy while encouraging informed decision-making.
A charge nurse agrees to cover another nurse's assignment during a lunch break. Based on the status report provided by the nurse who is leaving for lunch, which client should be checked first by the charge nurse?
- A. The client post triple coronary bypass four days ago who has serosanguinous drainage in one chest tube.
- B. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dL (10.8 mmol/L).
- C. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
- D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
Correct Answer: D
Rationale: The pneumothorax client with low oxygen saturation is at risk of respiratory failure, requiring immediate assessment.
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?
- A. Discuss why visitors should not lie in the bed with the client.
- B. Notify the charge nurse that the visitor is lying on the client's bed.
- C. Explain that the client has the right to have a visitor lie on the bed.
- D. Instruct the UAP to ask the visitor to get off the client's bed.
Correct Answer: D
Rationale: Instructing the UAP to address the visitor maintains hygiene and safety efficiently.
The nurse obtains verbal prescriptions from the healthcare provider for an antianginal, telemetry, and STAT serum analysis for cardiac isoenzymes, after reading back the prescriptions to the healthcare provider of a client's upper gastric burning, left jaw pain, and nausea. Which intervention is most important for the nurse to implement?
- A. Initiate telemetry and assess the client's cardiac rhythm.
- B. Document description of nausea and administer the antiemetic.
- C. Submit electronic prescriptions to the pharmacy and laboratory.
- D. Obtain the client's 10-point score for radiating jaw pain.
Correct Answer: A
Rationale: Initiating telemetry addresses potential myocardial infarction, a priority given the client's symptoms.