Nokea
The nurse in the emergency department (ED) is caring for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially
- A. developing a therapeutic rapport with the client.
- B. inserting a peripheral vascular access device.
- C. obtaining the client’s vital signs.
- D. collecting a serum lithium level on the client.
Correct Answer: B
Rationale: Inserting a peripheral vascular access device (B) is the initial priority in a lithium overdose to enable rapid administration of fluids or medications to stabilize the client. Vital signs (C) and lithium levels (D) follow, and rapport (A) is secondary to medical stabilization.
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The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality?
- A. Informing a visitor of the room number of a client admitted with pneumonia
- B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results
- C. Notifying the pharmacist that a client is HIV positive and may have a potential drug interaction
- D. Informing local authorities that a client is suspected of being a victim of domestic violence
Correct Answer: B
Rationale: Sharing drug screen results with police (B) violates confidentiality without consent or legal mandate, per HIPAA. Room number (A) is not protected, HIV disclosure for care (C) is permitted, and reporting suspected abuse (D) is legally required.
The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a
- A. collaborator
- B. team leader
- C. delegator
- D. manager
Correct Answer: A
Rationale: Collaborating with others across settings to achieve client-centered goals (A) defines the nurse’s role as a collaborator. Team leader (B) focuses on directing a group, delegator (C) assigns tasks, and manager (D) oversees operations, none of which fully capture this role.
The nurse overhears an unlicensed assistive personnel (UAP) shout at a client, 'you will have to get a feeding tube if you do not start eating more at mealtimes.' The nurse recognizes that the UAP has Select all that apply.
- A. committed battery.
- B. engaged in unprofessional conduct.
- C. committed assault.
- D. been negligent.
- E. demonstrated libel.
Correct Answer: B, C
Rationale: Shouting and threatening a feeding tube (B, C) constitutes unprofessional conduct (B) and assault (C), a verbal threat of harm. Battery (A) requires physical contact, negligence (D) involves failure of duty, and libel (E) is written defamation, none of which apply.
The nurse has received the following prescriptions for newly admitted clients. The nurse should first administer which of the following?
- A. Enoxaparin to a client with a platelet count of 165,000 mm3 (165 × 10^9/L) [150-400 mm3, 130-380 × 10^9/L]
- B. Warfarin to a client with an international normalized ratio of 2.4 [0.9-1.2 seconds]
- C. Packed red blood cells to a client with a hemoglobin of 6.1 g/dL (3.78 mmol/L) [Female: 12-16 g/dL, Male: 14-18 g/dL, Female 115-155 g/L, Male 125-170 g/L]
- D. Regular insulin to a client with a blood glucose of 285 mg/dL (15.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Correct Answer: C
Rationale: Packed red blood cells for hemoglobin of 6.1 g/dL (C) is the priority to address severe anemia, which can cause tissue hypoxia. Enoxaparin (A) is safe with normal platelets, warfarin (B) is therapeutic at INR 2.4, and insulin (D) is urgent but less critical than severe anemia.
The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is
- A. attending scheduled group therapy.
- B. adhere to the medication regimen.
- C. gain one pound (half a kilogram) a week.
- D. demonstrate increased self-esteem.
Correct Answer: C
Rationale: Gaining one pound (half a kilogram) per week (C) is the priority goal for anorexia nervosa to address life-threatening malnutrition and stabilize physical health. Attending group therapy (A), adhering to medications (B), and improving self-esteem (D) are important but secondary to restoring nutritional status to prevent organ failure.