Nokea
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.
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The nurse is caring for a client who reports having a durable power of attorney. The nurse understands that this type of advance directive is
- A. a person who makes decisions for a client once the health care provider states the client no longer has the capacity to make their own health care decisions.
- B. a legal document that tells health care providers and family members about which life-sustaining treatment is wanted or unwanted if the client is unable to make decisions.
- C. a legal document in which a client designates someone else to make medical decisions for them when the client can no longer do so.
- D. a specific designation specifying who can receive and discuss the client's privileged healthcare information.
Correct Answer: C
Rationale: A durable power of attorney for healthcare (C) is a legal document designating a proxy to make medical decisions when the client is incapacitated. Option (A) describes the role, not the document. Option (B) describes a living will, and (D) refers to HIPAA authorization, not an advance directive.
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.
The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply.
- A. drawing a line through the erroneous documentation.
- B. using correction tape and write over the error.
- C. writing over the error in darker ink.
- D. completely black out the error with a black marker.
- E. discarding the documentation in the trash and starting over.
- F. writing your initials, date, and time above the erroneous documentation with the word 'error.'
Correct Answer: A, F
Rationale: Correcting documentation errors involves drawing a single line through the error (A) and initialing, dating, and noting 'error' (F). Correction tape (B), writing over (C), blacking out (D), or discarding (E) are incorrect and violate documentation standards.
The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of
- A. beneficence.
- B. veracity.
- C. nonmaleficence.
- D. fidelity.
Correct Answer: B
Rationale: Honesty and openness (B) align with veracity, the ethical principle of truth-telling. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and fidelity (D) keeps promises, but veracity is most relevant here.
The nurse enters the room of a 5-year-old client and finds the client lying on the floor. The fall was unwitnessed. What is the priority nursing action?
- A. File an incident report
- B. Assist the child back to bed
- C. Call for help
- D. Assess the child for any injuries
Correct Answer: D
Rationale: Assessing the child for injuries (D) is the priority to identify potential harm, such as head trauma. Calling for help (C), assisting back to bed (B), and filing a report (A) follow after ensuring the child’s safety.