Nokea
The emergency department (ED) is caring for a client with a pulse (P) of 42, blood pressure (BP) of 90/60 mm Hg, and reports dizziness. Which of the following actions is the priority?
- A. Obtain an order for a chest radiograph (x-ray)
- B. Review the client's current medications
- C. Perform a focused neurological assessment
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: D
Rationale: A pulse of 42 with hypotension and dizziness (D) suggests symptomatic bradycardia, requiring an immediate ECG to identify arrhythmias, per ACLS guidelines. Chest x-ray (A), medication review (B), and neurological assessment (C) are secondary to cardiac evaluation.
You may also like to solve these questions
The nurse is conducting a staff in-service on client privacy. Which of the following actions would the nurse recognize as violations of client confidentiality? Select all that apply.
- A. Accessing a co-worker's address in their medical record to surprise them with a birthday gift.
- B. Reviewing a client's prescriptions with a student nurse who is assigned to the client.
- C. Looking up the medical information of a friend from a previous stay, even with their permission.
- D. Viewing a friend's medical record because you are listed as their power of attorney.
- E. Walking away from a computer terminal without securing it, even if the monitor is turned off.
Correct Answer: A, C, E
Rationale: Accessing a co-worker’s record for personal reasons (A), viewing a friend’s past record without current need (C), and leaving an unsecured computer (E) violate HIPAA confidentiality rules. Reviewing prescriptions with an assigned student (B) is educational, and viewing as power of attorney (D) may be authorized.
The charge nurse plans client care assignments for an unlicensed assistive personnel (UAP) and a licensed practical/vocational nurse (LPN/VN) in the medical-surgical unit. Which activity should the charge nurse delegate to the LPN/VN to maximize staff resources?
- A. Perform wound care and dressing changes
- B. Collect routine vital signs (VS)
- C. Turn all bedbound clients every two hours
- D. Ambulate clients with ambulation orders
Correct Answer: A
Rationale: Wound care and dressing changes (A) utilize the LPN/VN’s clinical skills, maximizing resources. Vital signs (B), turning (C), and ambulation (D) are within UAP scope, allowing the LPN/VN to focus on higher-skill tasks.
The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.
The nurse is conducting a teaching session with the parents of a child newly diagnosed with asthma. The priority topic for the nurse to cover is
- A. how to use a peak flow meter.
- B. signs and symptoms of an asthma attack.
- C. the need to stay current with immunizations.
- D. community resources available for asthma management.
Correct Answer: B
Rationale: Recognizing signs and symptoms of an asthma attack (B) is critical for parents to initiate prompt intervention, preventing severe exacerbations. Peak flow meter use (A), immunizations (C), and community resources (D) are important but secondary to immediate safety education.
The nurse is in an elevator and overhears two staff members discussing a client's condition. Which ethical principle does the nurse recognize may be potentially violated by this conversation?
- A. Beneficence
- B. Confidentiality
- C. Autonomy
- D. Veracity
Correct Answer: B
Rationale: Discussing a client’s condition in public violates confidentiality (B), as it breaches HIPAA and the client’s right to privacy. Beneficence (A), autonomy (C), and veracity (D) are unrelated to unauthorized disclosure of health information.