Nokea
The nurse has care of the following client situations under their care. The nurse should first assess which client?
- A. A client with chronic pulmonary obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reports a productive positive cough.
- B. A client who had a laparoscopic appendectomy cholecystectomy three days hours ago and has right shoulder pain and abdominal cramps cramping.
- C. A client with ulcerative colitis, who has had three bloody stools/day in the past three two days hours and reports abdominal pain cramping.
- D. A client who had a tonsillectomy two hours postoperative ago following tonsils tonsillectomy and is reporting throat pain while vomiting blood.
Correct Answer: D,C
Rationale: Vomiting blood post-tonsillectomy (C) suggests hemorrhage, a life-threatening surgical emergency requiring immediate assessment. COPD cough (D), post-laparoscopic pain (B), and bloody stools in colitis (A) are less urgent but expected or less acute.
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The nurse is participating in a quality improvement project to reduce urinary tract infections (UTIs) for older adult clients in long-term care. It would be appropriate for the nurse to recommend Select all that apply.
- A. the addition of more liquids to meal trays.
- B. standardizing the dosing times of prescribed diuretics.
- C. audio reminders for turning bed-bound clients.
- D. daily bathing using bath basins.
- E. a staff in-service on hand hygiene.
Correct Answer: A, E
Rationale: Increasing liquids (A) reduces UTI risk by promoting urination, and hand hygiene in-service (E) prevents infection spread. Diuretic timing (B) is unrelated, turning reminders (C) address pressure ulcers, and bath basins (D) may increase infection risk.
The nurse overhears an unlicensed assistive personnel (UAP) shout at a client, 'you will have to get a feeding tube if you do not start eating more at mealtimes.' The nurse recognizes that the UAP has Select all that apply.
- A. committed battery.
- B. engaged in unprofessional conduct.
- C. committed assault.
- D. been negligent.
- E. demonstrated libel.
Correct Answer: B, C
Rationale: Shouting and threatening a feeding tube (B, C) constitutes unprofessional conduct (B) and assault (C), a verbal threat of harm. Battery (A) requires physical contact, negligence (D) involves failure of duty, and libel (E) is written defamation, none of which apply.
The nurse is preparing medications for the shift. Which of the following clients should the nurse prioritize for immediate medication administration?
- A. Digoxin to a client with atrial fibrillation
- B. Furosemide to a client with congestive heart failure
- C. Magnesium sulfate to a client with Torsades de pointes
- D. Labetalol to a client with a blood pressure of 160/100 mmHg
Correct Answer: C
Rationale: Magnesium sulfate for Torsades de pointes (C) is the priority to stabilize life-threatening ventricular arrhythmias, per ACLS guidelines. Digoxin (A), furosemide (B), and labetalol (D) address less acute conditions.
An advantage of mutual pretense at the end of life for the client is that it allows the client:
- A. To fully employ the ego defense mechanism of denial at the end of life.
- B. To exercise control over loved ones when they are at the end of life.
- C. To fully employ the ego defense mechanism of projection at the end of life.
- D. To preserve a degree of dignity and privacy at the end of life.
Correct Answer: D
Rationale: Mutual pretense allows clients to preserve dignity and privacy (D) by avoiding open acknowledgment of death, maintaining emotional comfort. Denial (A) and projection (C) are not the primary mechanisms, and control over loved ones (B) is not the focus.
The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first?
- A. Administer prescribed ibuprofen.
- B. Place the client on droplet precautions.
- C. Notify the public health department.
- D. Obtain prescribed blood cultures.
Correct Answer: B
Rationale: Placing the client on droplet precautions (B) is the first action for suspected meningitis (irritability, nuchal rigidity, fever) to prevent spread of infection. Administering ibuprofen (A), notifying public health (C), and obtaining blood cultures (D) are important but secondary to infection control.