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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.
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A charge nurse is preparing client assignments for the shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?
- A. A client with a chest tube requiring frequent oral suctioning.
- B. A client receiving continuous IV heparin for a pulmonary embolism (PE).
- C. A client 24 hours post-abdominal surgery requiring daily wound care.
- D. A client with new-onset seizures awaiting diagnostic tests.
Correct Answer: C
Rationale: A client 24 hours post-abdominal surgery needing wound care (C) is stable and within the LPN scope. Chest tube suctioning (A) and heparin infusion (B) require RN monitoring for complications. New-onset seizures (D) require RN assessment due to instability.
The nurse is caring for a client with suspected meningitis. Which priority action should the nurse take following a lumbar puncture (LP) procedure?
- A. Assess the gag reflex
- B. Elevate the head of the bed to 30 degrees
- C. Encourage oral fluid intake
- D. Assess the client for Brudzinski sign
Correct Answer: C
Rationale: Encouraging oral fluid intake (C) post-lumbar puncture helps prevent spinal headache and supports recovery. Assessing gag reflex (A) is unrelated, elevating the head (B) depends on provider orders, and Brudzinski’s sign (D) is assessed before the procedure to diagnose meningitis, not after.
The emergency department (ED) nurse is assigned clients with assigned clients. Place the actions in the order of priority, starting with the highest priority.
- A. Dress a wound for a client discharged with multiple lacerations to the right arm.
- B. Insert a peripheral vascular access device for a client with mild dehydration and infuse prescribed fluids.
- C. Assess a client’s blood pressure who is receiving an infusion of dopamine.
- D. Witness informed consent for a client scheduled for surgery in six hours.
- E. Administer prescribed magnesium sulfate infusion for a client with status asthmaticus.
Correct Answer: C, E, B, D, A
Rationale: Assessing BP on dopamine (C) ensures hemodynamic stability, followed by magnesium for status asthmaticus (E) to control life-threatening bronchospasm. IV access for dehydration (B), informed consent (D), and wound dressing (A) are less urgent, as they address stable or non-emergent needs.
The nurse is caring for the following assigned clients. The nurse should prioritize following up with the client
- A. who had a myocardial infarction two days ago, and has an elevated troponin level.
- B. with infective endocarditis who wants to leave against medical advice (AMA).
- C. who has arterial insufficiency and is reporting leg pain after walking in the hall.
- D. recovering from cardiac catheterization, who has developed atrial fibrillation.
Correct Answer: D
Rationale: Atrial fibrillation post-cardiac catheterization (D) is a new, potentially unstable arrhythmia requiring immediate follow-up. Elevated troponin (A) is expected post-MI, AMA (B) needs discussion, and leg pain (C) is less urgent.
The nurse is caring for a client who reports having a durable power of attorney. The nurse understands that this type of advance directive is
- A. a person who makes decisions for a client once the health care provider states the client no longer has the capacity to make their own health care decisions.
- B. a legal document that tells health care providers and family members about which life-sustaining treatment is wanted or unwanted if the client is unable to make decisions.
- C. a legal document in which a client designates someone else to make medical decisions for them when the client can no longer do so.
- D. a specific designation specifying who can receive and discuss the client's privileged healthcare information.
Correct Answer: C
Rationale: A durable power of attorney for healthcare (C) is a legal document designating a proxy to make medical decisions when the client is incapacitated. Option (A) describes the role, not the document. Option (B) describes a living will, and (D) refers to HIPAA authorization, not an advance directive.