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The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?
- A. Monitor the client’s telemetry.
- B. Turn the client every two (2) hours.
- C. Administer oxygen via nasal cannula.
- D. Place the client in the Trendelenburg position.
Correct Answer: C
Rationale: Oxygen administration improves myocardial oxygenation, preventing cardiogenic shock post-MI. Telemetry monitors, turning prevents ulcers, and Trendelenburg is contraindicated.
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The nursing administrator responds to a code situation. When assessing the situation, which role must the administrator ensure is performed for legal purposes and continuity of care of the client?
- A. A person is ventilating with an Ambu bag.
- B. A person is performing chest compressions correctly.
- C. A person is administering medications as ordered.
- D. A person is keeping an accurate record of the code.
Correct Answer: D
Rationale: Accurate code documentation is critical for legal accountability and continuity of care. Ventilation, compressions, and medications are clinical priorities but less legally binding.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on a medical unit. Which nursing task cannot be delegated to the UAP?
- A. Obtaining the intake and output on a client diagnosed with food poisoning.
- B. Performing a dressing change on the client with a chemical burn.
- C. Assisting a client who overdosed on morphine to the bedside commode.
- D. Help a client with carbon monoxide poisoning turn, cough, and deep breathe.
Correct Answer: B
Rationale: Dressing changes on chemical burns require assessment and sterile technique, a nursing task. Intake/output, ambulation, and turning are delegable to UAPs.
Which statement best describes the role of the medical-surgical nurse during a disaster?
- A. The nurse may be assigned to ride in the ambulance.
- B. The nurse may be assigned as a first assistant in the operating room.
- C. The nurse may be assigned to crowd control.
- D. The nurse may be assigned to the emergency department.
Correct Answer: D
Rationale: Medical-surgical nurses are often reassigned to the ED during disasters to manage increased patient loads. Ambulance, OR, and crowd control roles are less typical.
The ED nurse is caring for a client with fractured pelvis and bladder trauma secondary to a motor-vehicle accident. Which data are most important for the nurse to assess?
- A. Monitor the creatinine and BUN.
- B. Check urine output hourly.
- C. Note the amount and color of the urine.
- D. Assess for bladder distention.
Correct Answer: C
Rationale: Amount and color of urine (e.g., hematuria) indicate bladder trauma severity, guiding intervention. Creatinine/BUN, output, and distention are important but secondary.
The elderly male client is admitted to the medical unit with a diagnosis of senile dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, both of whom work outside the house. Which referral is most important for the nurse to implement?
- A. Adult Protective Services.
- B. Social worker.
- C. Medicare ombudsman.
- D. Dietitian.
Correct Answer: A
Rationale: Low weight (54.5 kg for 74 inches, BMI ~16.5) and dementia suggest potential neglect, warranting Adult Protective Services referral. Social work, ombudsman, and dietitian are secondary.