Nokea
The emergency department (ED) nurse performs triage. Which client should the nurse prioritize care for? A client with
- A. hemophilia reporting knee and ankle stiffness with dizziness.
- B. chronic obstructive pulmonary disease (COPD) reporting a productive cough.
- C. chronic pericarditis reporting intermittent chest pain during inspiration.
- D. pain over the cheek radiating to the teeth, tenderness to percussion over the sinuses.
Correct Answer: A
Rationale: Hemophilia with joint stiffness and dizziness (A) suggests possible internal bleeding or anemia, a life-threatening emergency requiring immediate prioritization. COPD cough (B), pericarditis pain (C), and sinusitis (D) are less acute.
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The nurse has been made aware of the following client situations. The nurse should first assess the client that
- A. is in a private room, and their stage III pressure ulcer tests positive for Pseudomonas aeruginosa.
- B. is three hours post-operative from the placement of an ileostomy and has an edematous reddened stoma.
- C. has type 2 diabetes mellitus and a morning blood glucose of 76 mg/dL (4.2 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L], and refuses breakfast.
- D. is awaiting an appendectomy and reports increased pain with coughing and is relieved by bending the right hip.
Correct Answer: B
Rationale: An edematous, reddened stoma post-ileostomy (B) may indicate ischemia, requiring immediate assessment. Pseudomonas ulcer (A), low glucose with meal refusal (C), and appendicitis pain (D) are less urgent.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
A client has used a condescending tone towards the nurse, subsequently angering the nurse. Which response by the nurse would be most therapeutic?
- A. That tone of voice makes me feel upset.'
- B. You make me angry when you talk like that.'
- C. Are you trying to upset me?'
- D. Why do you use that tone of voice with me?'
Correct Answer: A
Rationale: Expressing feelings using 'I' statements (A) is therapeutic, promoting open communication without blame. Blaming the client (B), assuming intent (C), or questioning their tone (D) escalates conflict and is non-therapeutic.
The nurse offers to stay late to assist the next shift because they are short-staffed. Which ethical principle is the nurse demonstrating?
- A. Non-maleficence
- B. Paternalism
- C. C. Beneficence
- D. D. Veracity
Correct Answer: C
Rationale: Staying late to assist (C) demonstrates beneficence by acting to benefit staff and clients through additional support. Non-maleficence (A), paternalism (B), and veracity (D) do not apply to this act of goodwill.
The nurse is caring for a client admitted for an exacerbation of Meniere’s disease. Which of the following nursing interventions is of the highest priority when caring for this client?
- A. Determining if the client has experienced hearing loss.
- B. Initiating fall risk measures.
- C. Ensuring adherence to a low-sodium diet.
- D. Administering prescribed anticholinergic medications.
Correct Answer: B
Rationale: Initiating fall risk measures (B) is the highest priority in Meniere’s exacerbation due to vertigo, which poses an immediate safety risk. Hearing loss assessment (A), low-sodium diet (C), and medications (D) are important but secondary to preventing falls.