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The nurse has just received report on a group of clients and plans to delegate care of several of the clients to a practical nurse (PN). The first thing the RN should do before the delegation of care is
- A. Provide a time-frame for the completion of the client care
- B. Assure the PN that the RN will be available for assistance
- C. Ask about prior experience with similar clients
- D. Review the specific procedures unique to the assignment
Correct Answer: C
Rationale: The first step in delegation is to determine the qualifications of the person to whom one is delegating. By asking about the PN’s prior experience with similar clients/tasks, the RN can determine whether the PN has the requisite experience to care for the assigned clients.
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The nurse should visit which of the following clients first?
- A. The client with diabetes with a blood glucose of $95 \mathrm{mg} / \mathrm{dL}$
- B. The client with hypertension being maintained on Lisinopril
- C. The client with chest pain and a history of angina
- D. The client with Raynaud's disease
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible acute coronary syndrome, requiring immediate assessment to rule out myocardial infarction.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (5.8 mEq/L) is a serious spironolactone side effect, risking arrhythmias. Options B, C, and D are normal.
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
- A. Severe depression
- B. Violent behavior
- C. Respiratory distress
- D. Convulsions
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
- A. Nausea and vomiting
- B. Headache
- C. Dizziness
- D. Papilledema
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.
A woman who was recently diagnosed with multiple myeloma says to the nurse, 'Why did this happen to me? I've always been a good person. What did I do to deserve this?' What should the nurse do initially?
- A. Remind the client that she is not dying now and has some time left
- B. Call the chaplain to discuss why it happened to her
- C. Respond by recognizing how difficult this situation must be
- D. Tell her she didn't do anything to deserve it
Correct Answer: C
Rationale: Acknowledging the client's emotional distress validates her feelings, fostering therapeutic communication. Other responses dismiss or redirect her concerns.