Nokea
The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
- A. shallow respirations
- B. chest pain with repositioning
- C. bruising on the chest
- D. vomiting
Correct Answer: A
Rationale: Shallow respirations (A) in a client with rib fractures suggest impaired ventilation, risking hypoxia or pneumothorax, requiring immediate follow-up. Chest pain (B), bruising (C), and vomiting (D) are expected but less urgent.
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The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action?
- A. Notify public health services
- B. Dim the lights in the assigned room
- C. Obtain blood cultures
- D. Explore the client's feelings regarding the diagnosis
Correct Answer: C
Rationale: Obtaining blood cultures (C) is the priority action for suspected bacterial meningitis to confirm the diagnosis and guide antibiotic therapy. While droplet precautions (not listed) are also critical to prevent spread, cultures are the most urgent among the options. Notifying public health (A) is secondary, dimming lights (B) addresses comfort, and exploring feelings (D) is not a priority in an acute infection.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP? Select all that apply.
- A. Transport a client with an ankle fracture to radiology.
- B. Calculate and record a client's oral intake for the shift.
- C. Ambulate a client who is eight hours post-laparoscopic surgery.
- D. Assist a client with multiple sclerosis in performing oral care.
- E. Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.
Correct Answer: A, C, D
Rationale: UAPs can transport stable clients (A), ambulate post-surgical clients (C), and assist with oral care (D). Calculating intake (B) requires clinical judgment, and obtaining a urine culture (E) involves sterile technique, both RN/LPN tasks.
During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube. The nurse should initially
- A. obtain a specimen for culture.
- B. assess the drainage.
- C. place a sterile dressing around the gastrostomy tube.
- D. assess the client's temperature for fever.
Correct Answer: B
Rationale: Assessing the drainage (B) is the first step to determine the cause, such as infection or tube malfunction, guiding further action. Obtaining a culture (A), applying a dressing (C), or checking for fever (D) are secondary without initial assessment data.
The nurse manager reviews tasks delegated to unlicensed assistive personnel (UAP). Which of the following tasks requires follow-up by the nurse manager?
- A. providing perineal care to a client with an indwelling urinary catheter
- B. performing range of motion activities
- C. reminding the client how to care for their long-term colostomy
- D. ambulating a client who requires a gait belt
Correct Answer: C
Rationale: Reminding a client about colostomy care (C) involves teaching, which is outside the UAP’s scope and requires follow-up. Perineal care (A), range of motion (B), and ambulation with a gait belt (D) are appropriate UAP tasks.
The nurse preceptor educates the new graduate nurse that which of the following statements made by an elderly client indicate the achievement of ego integrity? Select all that apply.
- A. I wish I could change some things in my past.'
- B. I’d like to volunteer at the youth center a few days a week.'
- C. I’m thinking of helping people learn to read and write.'
- D. I signed up for an art class at the senior center.'
- E. I never achieved the career title I should have'
Correct Answer: B, C, D
Rationale: Volunteering (B), teaching literacy (C), and joining an art class (D) reflect ego integrity, showing life acceptance and purpose per Erikson’s theory. Regret over past (A) or career (E) indicates despair, not integrity.