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The nurse in the family clinic is checking the vital signs of clients. Which client should the nurse prioritize?
- A. A 9-month-old baby with a pulse rate of 148
- B. A 2-year-old with a respiratory rate of 30
- C. A 24-week pregnant woman with a blood pressure of 148/96 mmHg
- D. A 40-year-old man with a temperature of 37.8°C (100.04°F)
Correct Answer: C
Rationale: A blood pressure of 148/96 mmHg in a 24-week pregnant woman (C) suggests preeclampsia, a priority for immediate assessment. A pulse of 148 (A) and respiratory rate of 30 (B) are normal for infants and toddlers, and a mild temperature (D) is less urgent.
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The nurse is caring for assigned clients. The nurse should first assess the client
- A. with a right femur fracture who reports pain rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- B. with chronic obstructive pulmonary disease (COPD) who is reporting shortness of breath while ambulating in the hallway.
- C. with a history of T6 spinal injury 6 months ago, now reports a severe headache and is diaphoretic.
- D. one day postoperative from an open cholecystectomy with green drainage from the t-tube.
Correct Answer: C
Rationale: Severe headache and diaphoresis in a T6 spinal injury (C) suggest autonomic dysreflexia, a life-threatening emergency. COPD shortness of breath (B), femur fracture pain (A), and t-tube drainage (D) are less urgent.
The nurse is caring for a client experiencing an acute episode of vertigo. Which of the following actions would be a priority for the nurse?
- A. instruct the client to avoid sudden, jerky movements.
- B. Request a prescription for an antihistamine.
- C. Raise the upper side rails of the client's bed.
- D. Assess the client for nausea and vomiting.
Correct Answer: C
Rationale: Raising side rails (C) is the priority in acute vertigo to prevent falls due to dizziness, ensuring immediate safety. Avoiding movements (A), antihistamine (B), and nausea assessment (D) are important but secondary to fall prevention.
The nurse is reviewing leadership and management concepts with a student nurse. Which of the following statements by the student nurse would require follow-up?
- A. The Laissez-faire leadership style is a passive leadership approach.
- B. A registered nurse (RN) may delegate accountability to a licensed practical/vocational nurse (LPN/VN).
- C. The rights of delegation include task, circumstance, person, direction, supervision.
- D. The nurse practice act defines roles and responsibilities of nursing professionals.
Correct Answer: B
Rationale: The statement that RNs can delegate accountability to LPNs (B) is incorrect, as RNs remain accountable for delegated tasks. Laissez-faire leadership (A), delegation rights (C), and nurse practice acts (D) are accurately described, requiring no follow-up.
The nurse is providing the client with information regarding advanced directives. The nurse understands that giving this information supports the client's
- A. right to privacy.
- B. right to emergency care regardless of the ability to pay.
- C. C. self-determination.
- D. D. ability to receive appropriate treatment for their pain.
Correct Answer: C
Rationale: Advance directive discussions support self-determination (C) by empowering clients to make healthcare decisions. Privacy (A), emergency care (B), and pain treatment (D) are not directly related to advance directives.
A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.
- A. Remind the patient of why breast feeding is the best method of infant feeding.
- B. Request a referral to the lactation consultant.
- C. Determine the patient's knowledge base related to infant feeding options.
- D. Accept the patient's decision without further discussion.
Correct Answer: C
Rationale: Determining the patient’s knowledge base (C) respects her autonomy while ensuring informed decision-making, aligning with patient advocacy. Reminding about breastfeeding (A) or referring to a consultant (B) may pressure the patient, and accepting without discussion (D) neglects education.