Nokea
The nurse has received the following prescriptions for newly admitted clients. Which medication should the nurse administer first?
- A. Subcutaneous (SubQ) epoetin for anemia
- B. oxycodone by mouth (PO) for pain control
- C. Intravenous (IV) fluids for sepsis
- D. Intramuscular (IM) hydroxyzine for anxiety
Correct Answer: C
Rationale: IV fluids for sepsis (C) are the priority to restore perfusion and prevent organ failure. Epoetin (A) addresses chronic anemia, oxycodone (B) manages pain, and hydroxyzine (D) treats anxiety, all less urgent than sepsis.
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The nurse is caring for assigned clients. The nurse should prioritize seeing the client who
- A. has a chest tube attached to a closed-chest drainage system to treat a pneumothorax and reports increased dyspnea and dizziness.
- B. is being treated for acute pancreatitis and reports nausea and pain rated 6 on a scale of 0 (no pain) to 10 (severe pain).
- C. is being treated for pheochromocytoma and reports a headache, and most recent blood pressure is 149/84 mm Hg.
- D. has pneumonia with atelectasis and has had decreased breath sounds in the affected lobe.
Correct Answer: A
Rationale: Dyspnea and dizziness with a chest tube for pneumothorax (A) suggest complications like tube malfunction or hemothorax, requiring immediate assessment. Pancreatitis pain (B), headache with pheochromocytoma (C), and decreased breath sounds in pneumonia (D) are less urgent.
The nurse in the emergency department (ED) has a client with suspected septic shock. The priority intervention for this client is to
- A. establish a peripheral vascular access device.
- B. obtain the prescribed consult with infectious disease.
- C. provide frequent updates regarding the client's care.
- D. perform a physical assessment for the potential source of infection.
Correct Answer: A
Rationale: Establishing a peripheral vascular access device (A) is the priority in septic shock to enable rapid fluid and medication administration. Infectious disease consult (B), care updates (C), and source assessment (D) follow after stabilizing access.
The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
- A. A 65-year-old male requiring sterile dressing changes.
- B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
- C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
- D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.
Correct Answer: B
Rationale: Assisting a client with ambulation (B) is a non-clinical task within the UAP’s scope. Sterile dressing changes (A), enteral feedings (C), and catheter specimen collection (D) require clinical judgment or training beyond UAP scope.
The nurse is discussing information about advanced directives with a client who expresses concerns, asking, 'What if I change my mind about what I want?' What approach would you use to respond to the client's care?
- A. Explain that the client would have to file a new witnessed document in order to make any changes.
- B. Discuss the need to be very sure about his preferences, as the living will is a binding legal document.
- C. Assure the client that he can change or revoke his advanced directives at any time.
- D. Advise the client that changes could not be made during this hospital stay.
Correct Answer: C
Rationale: Clients can change or revoke advance directives at any time (C), ensuring autonomy. New documents (A) may be needed but not restrictive, living wills are not unchangeable (B), and hospital stay (D) does not limit changes.
A patient has completed a living will stating that he does not want intubation, mechanical ventilation, or artificial nutrition/hydration should he become unable to communicate his preferences related to medical care. However, the patient's adult children have expressed their opposition to the patient's wishes. Which are appropriate nursing actions? Select all that apply.
- A. Notify the patient's physician, the nursing supervisor, and the risk manager.
- B. Explain to the patient's family that the living will cannot be changed at this point.
- C. Encourage the family to discuss their feelings to try to resolve this issue.
- D. Request a consult with the facility ethics committee if needed.
- E. Advise the patient to just go along with the wishes of his adult children.
Correct Answer: A, C, D
Rationale: Notifying leadership (A), encouraging family discussion (C), and requesting an ethics consult (D) respect the client’s autonomy while addressing family concerns. Stating the will cannot be changed (B) is incorrect, and advising compliance with family (E) violates autonomy.