Nokea
The nurse has been made aware of the following client situations. The nurse should first follow up with the client
- A. receiving a chemotherapy infusion who reports nausea and vomiting.
- B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain.
- C. being treated for aplastic anemia and has a temperature of 101.1°F (38.4°C).
- D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.
Correct Answer: C
Rationale: A fever in a client with aplastic anemia (C) indicates potential infection, a life-threatening complication due to low white blood cells, requiring immediate attention. Nausea from chemotherapy (A), hematuria with kidney disease (B), and TB with a mask (D) are less urgent.
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The nurse plans care for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Place gowns and gloves outside of the client’s room
- B. Educate the client and family members on ways to prevent transmission of VRE
- C. Affix a droplet precautions sign on the client’s door
- D. Validate the client’s understanding on hand hygiene
Correct Answer: A
Rationale: Placing gowns and gloves outside the room (A) is a non-clinical task within the UAP’s scope. Education (B), signage for droplet precautions (C, incorrect for VRE), and validating understanding (D) require clinical judgment and are RN/LPN responsibilities.
After talking to a her family, an elderly client says that she wants to change their living will she wrote two weeks ago. The nurse's most appropriate reply would be:
- A. You can only change your living will a year after it is formulated.
- B. Let me see if I can find someone to help you.
- C. You cannot only make changes to your will after 3 weeks.
- D. Let's call your lawyer first and see what he thinks they think.
Correct Answer: B
Rationale: The nurse should assist the client by finding someone to help (B), such as a social worker or legal resource, to facilitate changes to the living will. There are no time restrictions (A, C), and contacting a lawyer (D) is unnecessary unless requested by the client.
The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style?
- A. Authoritative
- B. Democratic
- C. C. Laissez-Faire
- D. D. Transactional
Correct Answer: B
Rationale: A unit-based council reflects a democratic leadership style (B), involving staff in decision-making. Authoritative (A) is directive, laissez-faire (C) is passive, and transactional (D) focuses on rewards and tasks, not shared governance.
The nurse manager regularly performs chart audits and room inspections in the unit. They tell the staff to address the unit's deficiencies during a meeting. Which concept of management is the nurse manager displaying?
- A. Benchmarking
- B. Continuous Quality Improvement
- C. Performance Improvement
- D. Quality Management
Correct Answer: B
Rationale: Addressing deficiencies through audits and staff meetings (B) reflects continuous quality improvement, focusing on ongoing process enhancement. Benchmarking (A) compares to external standards, performance improvement (C) is specific to outcomes, and quality management (D) is broader.
A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?
- A. I will sign as a witness to your signature.'
- B. Because it is a legal document, you will need to find a witness on your own.'
- C. Whoever is present at the time will sign as a witness for you.'
- D. I will contact the nursing supervisor for assistance regarding your request.'
Correct Answer: D
Rationale: Contacting the nursing supervisor (D) ensures compliance with legal witnessing requirements, as nurses may be restricted due to conflict of interest. Signing as a witness (A), leaving it to the client (B), or allowing anyone present (C) risks legal issues.