Nokea
The nurse enters a client's room and finds the client lying on the floor and appearing unresponsive. The nurse should initially
- A. initiate a code blue.
- B. assess the client's respiratory effort.
- C. assess the carotid pulse.
- D. shout the client's name.
Correct Answer: B
Rationale: Assessing respiratory effort (B) is the initial step for an unresponsive client to determine if breathing is present, guiding further action. Shouting (D), checking pulse (C), or initiating a code (A) follow assessment.
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The nurse knows that the concept of management is most closely associated with:
- A. Decision-making, problem-solving, and priority setting.
- B. Inspirational abilities and coaching.
- C. Visionary abilities and supervision.
- D. Motivational and visionary abilities.
Correct Answer: A
Rationale: Management is closely associated with decision-making, problem-solving, and priority setting (A), which are core functions of organizing and coordinating care. Inspirational (B), visionary (C), and motivational (D) abilities align more with leadership than management.
The nurse is teaching a leadership and management course and is discussing client referrals. Which of the following statements best describes the purpose of referrals?
- A. Allows the nurse to demonstrate their leadership abilities.
- B. Care is appropriately routed to an individual or discipline.
- C. Ensures that care is unilateral and cost-effective.
- D. Focuses on empowering the client's decision making.
Correct Answer: B
Rationale: Referrals (B) ensure care is directed to the appropriate specialist or discipline to meet the client’s needs effectively. Demonstrating leadership (A) is secondary. Referrals do not ensure unilateral care (C) and are not primarily about client empowerment (D), though they may support it.
The nurse is planning client assignments in the mental health unit. Which task should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)?
- A. conduct a suicide assessment on a newly admitted client
- B. administering prescribed lithium to a client with bipolar disorder
- C. leading a group therapy session for clients with depressive disorders
- D. monitoring a client who is talking on the phone to a family member
Correct Answer: B
Rationale: Administering prescribed lithium (B) is within the LPN’s scope, involving medication administration to a stable client. Suicide assessment (A) and group therapy (B) require RN expertise, and monitoring phone calls (C) is a UAP task, making these inappropriate for LPN delegation (D).
The nurse is caring for the following assigned clients. The nurse should immediately follow up with the client who has
- A. mechanical ventilation and the low-pressure alarm sounds.
- B. a new colostomy with refusal to participate in care.
- C. acute glomerulonephritis and has periorbital edema.
- D. atrial fibrillation with an irregular pulse.
Correct Answer: A
Rationale: A low-pressure ventilator alarm (D) suggests a leak or disconnection, risking airway compromise, requiring immediate follow-up. Colostomy refusal (A), periorbital edema (B), and irregular pulse in AF (C) are less urgent, as they are chronic or stable.
The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply.
- A. At the start of the interview, inquire about the client's preferred pronoun.'
- B. Utilize binary gender terms on healthcare documentation.'
- C. Transgender individuals feel a variance between gender and natal sex.'
- D. Clients who are transgender may be reluctant to seek healthcare.'
- E. Inquire about any current or future plans for hormone therapy.'
Correct Answer: A, C, D, E
Rationale: Inquiring about pronouns (A), recognizing gender variance (C), acknowledging healthcare reluctance (D), and discussing hormone therapy (E) are inclusive and relevant. Binary gender terms (B) are inappropriate, as they exclude non-binary identities.