Nokea
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.
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The nurse on the medical-surgical unit has received two new client admissions simultaneously. Which assessment is essential to determine which client the nurse should see first?
- A. Vital signs
- B. Number of prescribed medications
- C. Medical history
- D. Code status
Correct Answer: A
Rationale: Vital signs (A) are essential to determine which new admission to assess first, as they indicate immediate physiological stability or instability. Medications (B), medical history (C), and code status (D) are important but secondary to detecting life-threatening conditions.
The nurse has received a change-of-shift report for assigned clients. The nurse should initially followup on the client with
- A. cystic fibrosis who is coughing up a large amount of yellow mucus.
- B. cellulitis in the lower extremity reporting pain rated 6/10 on the Numerical Rating Scale.
- C. chronic obstructive pulmonary disease reporting blood-tinged sputum 4 hours after a bronchoscopy.
- D. dumping syndrome reporting blurred vision and disorientation.
Correct Answer: A
Rationale: Yellow mucus in cystic fibrosis (A) suggests a possible infection or exacerbation, requiring immediate assessment to prevent respiratory compromise. Cellulitis pain (B), post-bronchoscopy sputum (C), and dumping syndrome symptoms (D) are less urgent, though blurred vision in (D) warrants monitoring.
Client One, prednisone 10 mg PO Daily for asthma exacerbation
Client Two, acetaminophen 500 mg PO x 1 dose for fever
Client Three, magnesium oxide 250 mg PO Daily For chronic dode 150 mg PO Daily
Client Four, glargine insulin 15 units SubQ Daily for diabetes mellitus
The nurse is performing medication administration for four clients. Which client and medication should be administered first?
- A. Client One
- B. Client Two
- C. Client Three
- D. Client Four
Correct Answer: B
Rationale: Acetaminophen for fever (B) is the priority to address an acute symptom that may indicate infection or discomfort, requiring timely intervention. Prednisone (A), magnesium oxide (C), and glargine insulin (D) are daily medications with less immediate urgency.
The nurse is caring for a client who is asking about advanced directives. Many documents fall under the category of an advanced directive. The nurse knows that one of the most common legal papers is called 'Durable Power of Attorney for Health Care' and works to:
- A. Review a person's personal preferences for medical care in the future.
- B. Authorize another person to make medical decisions for a person if they become unable to on their own.
- C. Assign a legal authority in making medical decisions while honoring the spoken word of the family.
- D. Define what care should be administered or withheld by health care professionals, no matter which medical facility the patient finds themselves in.
Correct Answer: B
Rationale: A Durable Power of Attorney for Health Care (B) authorizes a designated person to make medical decisions if the client is incapacitated. Reviewing preferences (A) describes a living will. Honoring family wishes (C) is not legally binding, and defining care across facilities (D) overstates its scope.
The nurse is preparing to sign a client's surgical consent form after the physician has explained the procedure to the client and family. As the client signs the form, she comments 'I really didn’t understand most of what the doctor said, but I have to have this procedure, so I want to sign.' Which is the appropriate nursing action?
- A. Witness the document, as the client states she wants to sign it.
- B. Notify the physician or nursing supervisor.
- C. Call the OR to cancel the procedure and reschedule at a later date.
- D. Explain the information she did not understand.
Correct Answer: B
Rationale: Notifying the physician or nursing supervisor (B) ensures informed consent, a legal and ethical requirement, by addressing the client’s lack of understanding. Witnessing without clarification (A) violates consent principles, canceling the procedure (C) is premature, and explaining as a nurse (D) may exceed the nurse’s role, as the physician should clarify procedure details.