Nokea
The nurse has been made aware of the following client situations. The nurse should first assess the client
- A. who recently received tissue plasminogen activator (tPA) and has oozing at the insertion site of the peripheral vascular access device.
- B. who has acute kidney injury (AKI) and has voided 100 mL of urine in the past six hours.
- C. who has pericarditis and is sitting upright in the bed, leaning forward to help relieve the chest pain.
- D. has an intractable migraine headache and has vomited twice in the past two hours.
Correct Answer: A
Rationale: Oozing at the tPA insertion site (A) suggests bleeding risk, a critical complication due to thrombolytic therapy, requiring immediate assessment. Oliguria in AKI (B), pericarditis pain relief (C), and migraine with vomiting (D) are less urgent.
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The nurse reviews the nursing process with a group of students. Which of the following would demonstrate implementation? Select all that apply.
- A. Performing a sterile dressing change
- B. Interviewing the client about their social determinants
- C. Inputs risk for impaired skin integrity into the care plan
- D. Establishing a peripheral vascular access device
- E. Determining if the prescribed pain medication was effective
Correct Answer: A, D
Rationale: Performing a dressing change (A) and establishing IV access (D) are implementation actions, executing the care plan. Interviewing (B) is assessment, inputting risks (C) is planning, and determining medication effectiveness (E) is evaluation.
The nurse is caring for a client receiving nasal cannula oxygen and prescribed warfarin for venous thromboembolism (VTE) prevention. The unlicensed assistive personnel (UAP) informs the nurse that the client has a nose bleed. The nurse should initially
- A. have the unlicensed assistive personnel (UAP) apply petroleum water-soluble jelly to nares.
- B. review the most recent activated partial thromboplastin time (aPTT).
- C. assess the client for bruising and bleeding gums.
- D. obtain an order to humidify the oxygen.
Correct Answer: C
Rationale: Assessing for bruising and bleeding gums (C) evaluates the extent of bleeding risk on warfarin. Applying jelly (A) is inappropriate, reviewing aPTT (B) is secondary, and humidifying oxygen (D) is not urgent.
The nurse is participating in a committee with the objective of promoting healthcare justice in the community. Which of the following recommendations should the nurse make to achieve the goal?
- A. establishing interdisciplinary collaboration between nursing and nutritional services
- B. providing more confidential waste containers at local drug stores
- C. offering free telehealth offerings in underserved areas of the community
- D. offering inpatient clients the ability to select their meal times
Correct Answer: C
Rationale: Free telehealth in underserved areas (C) promotes healthcare justice by improving access for disadvantaged populations. Interdisciplinary collaboration (A), waste containers (B), and meal time selection (D) are beneficial but less directly address equitable access.
A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
- A. Document the refusal
- B. Notify the primary healthcare provider (PHCP)
- C. Review the client's most recent platelet count
- D. Inquire with the client about the refusal
Correct Answer: D
Rationale: Inquiring about the refusal (D) allows the nurse to understand the client’s concerns, provide education, and address barriers, promoting informed decision-making. Documenting (A) and notifying the provider (B) are secondary steps, and reviewing platelet count (C) is irrelevant without addressing the refusal first.
During a disaster triage situation with limited ICU beds and resources, the nurse must recommend which clients should receive priority for ICU admission. Which of the following clients should be prioritized? Select all that apply.
- A. A client with a flail chest and respiratory distress requiring intubation
- B. A client with a Glasgow Coma Scale (GCS) score of 3 and fixed pupils
- C. A client with septic shock responding to vasopressors and fluids
- D. A client with extensive full-thickness burns over 85% of the total body surface area
- E. A client with an open leg fracture and stable vital signs
- F. A client with a traumatic brain injury and signs of increasing intracranial pressure
Correct Answer: A, C, F
Rationale: Clients with flail chest requiring intubation (A), septic shock responding to treatment (C), and traumatic brain injury with increasing intracranial pressure (F) have salvageable conditions needing ICU care. GCS of 3 with fixed pupils (B) indicates poor prognosis, extensive burns (D) have low survival likelihood, and stable leg fracture (E) is non-critical.