Nokea
The nurse in the emergency department (ED) is caring for a client diagnosed with acute pancreatitis. The nurse should prioritize obtaining a prescription for
- A. intravenous fluids.
- B. ondansetron.
- C. the insertion of a nasogastric tube (NGT).
- D. fentanyl via patient-controlled analgesia.
Correct Answer: A
Rationale: IV fluids (A) are the priority in acute pancreatitis to correct hypovolemia and prevent organ failure, per clinical guidelines. Ondansetron (B), NGT (C), and fentanyl (D) address symptoms but are secondary to fluid resuscitation.
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The nurse is preparing to insert an indwelling urinary catheter. Which action may be delegated to the unlicensed assistive personnel (UAP)?
- A. Set up the sterile field
- B. Palpate the bladder for distention
- C. Explain the procedure to the client
- D. Place the urinary catheter kit at the bedside
Correct Answer: D
Rationale: Placing the catheter kit at the bedside (D) is a non-clinical task suitable for a UAP. Setting up a sterile field (A), palpating the bladder (B), and explaining the procedure (C) require clinical judgment or training beyond UAP scope.
A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?
- A. I will sign as a witness to your signature.'
- B. Because it is a legal document, you will need to find a witness on your own.'
- C. Whoever is present at the time will sign as a witness for you.'
- D. I will contact the nursing supervisor for assistance regarding your request.'
Correct Answer: D
Rationale: Contacting the nursing supervisor (D) ensures compliance with legal witnessing requirements, as nurses may be restricted due to conflict of interest. Signing as a witness (A), leaving it to the client (B), or allowing anyone present (C) risks legal issues.
The nurse plans care for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Place gowns and gloves outside of the client’s room
- B. Educate the client and family members on ways to prevent transmission of VRE
- C. Affix a droplet precautions sign on the client’s door
- D. Validate the client’s understanding on hand hygiene
Correct Answer: A
Rationale: Placing gowns and gloves outside the room (A) is a non-clinical task within the UAP’s scope. Education (B), signage for droplet precautions (C, incorrect for VRE), and validating understanding (D) require clinical judgment and are RN/LPN responsibilities.
The nurse is planning to interview a client interested in establishing care with a primary healthcare provider (PHCP). The nurse should initially
- A. obtain the client's vital signs.
- B. identify the client's chief complaint.
- C. provide a private area for the interview.
- D. inquire about the client's allergies.
Correct Answer: C
Rationale: Providing a private area (C) ensures confidentiality and comfort, the initial step for an interview. Chief complaint (B), allergies (D), and vital signs (A) follow after establishing privacy.
The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.