Nokea
The nurse has been made aware of the following client situations. The nurse should first assess the client
- A. with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 90%.
- B. being treated for hypertension and has a blood pressure of 151/95 mm Hg and complains of a headache.
- C. with a urinary catheter in place who is experiencing fever and chills.
- D. with a chest tube attached to a closed-chest drainage system that reports the onset of dyspnea.
Correct Answer: D
Rationale: Dyspnea with a chest tube (D) suggests complications like tube occlusion or pneumothorax, requiring immediate assessment to ensure airway and breathing stability. COPD saturation (A), hypertension with headache (B), and catheter-related fever (C) are less urgent.
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The nurse is caring for assigned clients. The nurse should initially assess the client who has
- A. left pulmonary empyema, a temperature of 102.4°F (39.1°C), and a pulse of 104.
- B. gentle bubbling in the water seal chamber of their chest tube when exhaling.
- C. a right pleural effusion and has decreased tactile fremitus in the right lobe.
- D. pneumonia and has a pulse oximetry of 90% while on 4 liters of nasal cannula oxygen.
Correct Answer: A
Rationale: Fever (102.4°F) and tachycardia (104) in empyema (A) suggest worsening infection or sepsis, requiring immediate assessment. Chest tube bubbling (B) is normal, pleural effusion findings (C) are expected, and 90% saturation (D) is stable with oxygen.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG).
- B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools.
- C. diabetes mellitus who refuses to eat following the administration of glargine insulin.
- D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Black, tarry stools in a client on warfarin (B) suggest gastrointestinal bleeding, a life-threatening complication requiring immediate assessment. Respiratory acidosis (A) is concerning but less acute if stable. Refusing to eat post-insulin (C) risks hypoglycemia but is less urgent. Pancreatitis pain (D) rated 3/10 is manageable.
The nurse overhears another nurse state to a client 'If you do not behave, I will restrain you.' This statement demonstrates an example
- A. battery.
- B. libel.
- C. slander.
- D. assault.
Correct Answer: D
Rationale: Threatening restraint for behavior (D) is assault, a verbal threat of harm without physical contact, per legal definitions in healthcare. Battery (A) requires physical contact, libel (B) is written defamation, and slander (C) is spoken defamation, none of which apply.
The nurse manager has been made aware of the following staff nurse issues. The manager should initially follow up on the staff nurse who
- A. falsified documentation on a client discharged within the last 24 hours.
- B. needs assistance completing an incident report about a medication administration error on the previous shift.
- C. was thirty minutes late and tardy to their shift and is not wearing the correct gown uniform.
- D. is suspected of alcohol impairment and is precepting a newly hired nurse.
Correct Answer: D
Rationale: Suspected alcohol impairment while precepting (C) poses an immediate safety risk to clients and staff, requiring immediate immediate manager intervention. Falsified documentation (D), incident report assistance (A), and tardiness/uniform issues (B) are serious but less urgent than impairment.
The nurse is caring for assigned clients. The nurse should initially follow up on the client who is
- A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C).
- B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side.
- C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous.
- D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.
Correct Answer: B
Rationale: Absent breath sounds with a chest tube for pneumothorax (B) indicate a life-threatening complication, such as tube dislodgement or re-collapse, requiring immediate assessment. A fever post-hypophysectomy (A) suggests infection but is less urgent. Nervousness from albuterol (C) is a common side effect, and cramping during dialysis (D) is less critical unless severe.