Nokea
“ Initiate intravenous fluids to a client with anorexia nervosa
Administer venlafaxine to a client with persistent depressive disorder
Consult the social worker to begin discharge planning for a client
Obtain a blood sample to evaluate a client's lithium level”
The nurse has received the following prescriptions for newly admitted clients. The nurse should initially implement which of the following?
- A. initiate intravenous fluids to a client with anorexia nervosa.
- B. administer venlafaxine to a client with persistent depressive disorder.
- C. consult the social worker to begin discharge planning for a client.
- D. obtain a blood sample to evaluate a client's lithium level.
Correct Answer: A
Rationale: Initiating IV fluids for anorexia nervosa (A) is the priority to address life-threatening dehydration and electrolyte imbalances. Administering venlafaxine (B), consulting a social worker (C), and obtaining a lithium level (D) are less urgent, as they do not address immediate physiological threats.
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A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
The nurse is in an elevator and overhears two staff members discussing a client's condition. Which ethical principle does the nurse recognize may be potentially violated by this conversation?
- A. Beneficence
- B. Confidentiality
- C. Autonomy
- D. Veracity
Correct Answer: B
Rationale: Discussing a client’s condition in public violates confidentiality (B), as it breaches HIPAA and the client’s right to privacy. Beneficence (A), autonomy (C), and veracity (D) are unrelated to unauthorized disclosure of health information.
The nurse is caring for the following assigned clients. The nurse should immediately follow up with the client who has
- A. mechanical ventilation and the low-pressure alarm sounds.
- B. a new colostomy with refusal to participate in care.
- C. acute glomerulonephritis and has periorbital edema.
- D. atrial fibrillation with an irregular pulse.
Correct Answer: A
Rationale: A low-pressure ventilator alarm (D) suggests a leak or disconnection, risking airway compromise, requiring immediate follow-up. Colostomy refusal (A), periorbital edema (B), and irregular pulse in AF (C) are less urgent, as they are chronic or stable.
The nursing student inserts an indwelling urinary catheter for a female patient prior to surgery. Which of the following would require immediate intervention by the RN?
- A. The patient states she feels the need to urinate.
- B. Patient reports a pinching sensation as the catheter is advanced.
- C. The student nurse notes resistance when inflating the balloon.
- D. The student separates the labia majora and labia minora with non-dominant hand.
Correct Answer: C
Rationale: Resistance when inflating the catheter balloon (C) suggests improper placement (e.g., in urethra), risking trauma, requiring immediate RN intervention. Urge to urinate (A) and pinching (B) are normal, and labia separation (D) is correct technique.
The nurse knows that the concept of management is most closely associated with:
- A. Decision-making, problem-solving, and priority setting.
- B. Inspirational abilities and coaching.
- C. Visionary abilities and supervision.
- D. Motivational and visionary abilities.
Correct Answer: A
Rationale: Management is closely associated with decision-making, problem-solving, and priority setting (A), which are core functions of organizing and coordinating care. Inspirational (B), visionary (C), and motivational (D) abilities align more with leadership than management.