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The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. pancreatitis who has developed bruising around the umbilicus.
- B. a capillary blood glucose of 159 mg/dL (8.83 mmol/L) [70-110 mg/dL; 4-6 mmol/L] while receiving total parenteral nutrition.
- C. a blood pressure of 156/92 mmHg who sustained an ischemic stroke six hours ago.
- D. stable angina reporting headache while receiving nitroglycerin via transdermal patch.
Correct Answer: A
Rationale: Umbilical bruising in pancreatitis (A) suggests Cullen’s sign, indicating possible retroperitoneal hemorrhage, a life-threatening emergency. Mild hyperglycemia (B), elevated BP post-stroke (C), and nitroglycerin headache (D) are less urgent, as they are expected or manageable.
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The nurse has been made aware of the following client situations. The nurse should first assess the client
- A. with chronic obstructive pulmonary disease (COPD) who has an oxygen saturation of 90%.
- B. being treated for hypertension and has a blood pressure of 151/95 mm Hg and complains of a headache.
- C. with a urinary catheter in place who is experiencing fever and chills.
- D. with a chest tube attached to a closed-chest drainage system that reports the onset of dyspnea.
Correct Answer: D
Rationale: Dyspnea with a chest tube (D) suggests complications like tube occlusion or pneumothorax, requiring immediate assessment to ensure airway and breathing stability. COPD saturation (A), hypertension with headache (B), and catheter-related fever (C) are less urgent.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN? Select all that apply. A client
- A. receiving oral antibiotics for lower extremity cellulitis.
- B. newly admitted with an exacerbation of myasthenia gravis.
- C. with a chest tube and receiving mechanical ventilation.
- D. requiring a referral to an outpatient support group.
- E. needing to receive intramuscular RhoGAM.
- F. needing scheduled tube feedings and colostomy irrigations.
Correct Answer: A, E, F
Rationale: Oral antibiotics for cellulitis (A), intramuscular RhoGAM (E), and tube feedings/colostomy irrigations (F) are stable tasks within the LPN’s scope. Myasthenia gravis exacerbation (B), chest tube/ventilation (C), and support group referral (D) require RN assessment or coordination due to instability or complexity.
The nurse is discussing management styles with a colleague. Which of the following nursing leadership and management-related statements is accurate?
- A. Nurse managers possess personal accountability for not only their specific acts but also acts of delegation and supervision.
- B. Nurses and nurse managers are accountable for supervising others, except for unlicensed assistive personnel (UAP).
- C. When delegated to the appropriate person, the delegating nurse is no longer responsible for ensuring the task is performed correctly.
- D. Managing care entails micromanagement of the unit's staff.
Correct Answer: A
Rationale: Nurse managers are accountable for their actions and delegated tasks, including supervision (A), per nursing standards. UAPs are included in supervision (B), delegators remain responsible (C), and micromanagement (D) is ineffective, not a management goal.
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.
The nurse is caring for assigned clients. The nurse should initially assess the client who has
- A. left pulmonary empyema, a temperature of 102.4°F (39.1°C), and a pulse of 104.
- B. gentle bubbling in the water seal chamber of their chest tube when exhaling.
- C. a right pleural effusion and has decreased tactile fremitus in the right lobe.
- D. pneumonia and has a pulse oximetry of 90% while on 4 liters of nasal cannula oxygen.
Correct Answer: A
Rationale: Fever (102.4°F) and tachycardia (104) in empyema (A) suggest worsening infection or sepsis, requiring immediate assessment. Chest tube bubbling (B) is normal, pleural effusion findings (C) are expected, and 90% saturation (D) is stable with oxygen.