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The nurse has been made aware that the following clients require assistance. The nurse should first assist the client
- A. experiencing a flare-up of ulcerative colitis and has had 2 bloody bowel movements in the past hour.
- B. with a cerebral aneurysm, has developed nausea and vomiting.
- C. taking prescribed prednisone for an allergic reaction and reports indigestion.
- D. being treated for Bell's palsy and reports ringing in their ears.
Correct Answer: A
Rationale: Bloody bowel movements in ulcerative colitis (A) suggest active bleeding, requiring immediate assistance to prevent hypovolemia. Nausea with aneurysm (B), indigestion with prednisone (C), and tinnitus with Bell’s palsy (D) are less urgent.
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The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who is
- A. receiving albuterol via a nebulizer and reports feeling 'nervous'.
- B. awaiting a home healthcare referral following total hip arthroplasty.
- C. six hours post-op from a hysterectomy and is reporting nausea.
- D. reporting that their arm is 'sleeping' after having a cast for a fracture applied three hours ago.
Correct Answer: D
Rationale: Numbness ('sleeping' arm) post-cast application (D) suggests possible compartment syndrome or nerve compression, a surgical emergency requiring immediate follow-up. Nervousness from albuterol (A) is expected, home health referral (B) is non-urgent, and post-op nausea (C) is common but less critical.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
- A. A client with a blood glucose of 250 mg/dL [70–100 mg/dL, 4.0–5.6 mmol/L] who is requesting insulin coverage.
- B. A client post-thyroidectomy with a hoarse voice and difficulty speaking.
- C. A client with pneumonia reporting shortness of breath after ambulating.
- D. A client post-cholecystectomy requesting pain medication for a pain score of 7/10 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Hoarse voice and difficulty speaking post-thyroidectomy (B) suggest possible laryngeal nerve damage or hypocalcemia, life-threatening complications requiring immediate assessment. High glucose (A), shortness of breath (C), and pain (D) are less acute.
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.
A nurse is performing disaster triage at a field hospital following a structural collapse. Advanced life support resources are limited. Which client should be assigned a black tag?
- A. A client with a penetrating head wound, unresponsive to pain, irregular respirations, and a fixed, dilated pupil
- B. A client with a chest wall bruise, shallow respirations, and tracheal deviation to the right
- C. A client with an open femur fracture, cool extremity, delayed capillary refill, and confusion
- D. A client who is found conscious, but unable to move the legs, with a distended abdomen and bruising across the lower torso
Correct Answer: A
Rationale: A black tag (A) is assigned to clients unlikely to survive, such as one with a penetrating head wound, unresponsive, irregular respirations, and fixed pupil, indicating severe brain injury. Chest trauma (B), femur fracture (C), and spinal/abdominal injury (D) have higher survival potential.
The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.