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The nurse is admitting a new client and begins to review information regarding advanced directives. The client becomes agitated and refuses to discuss the issue or accept a handout about the topic. Which is the appropriate nursing action?
- A. Leave the handout on the client's bedside table instructing him that he must review the content.
- B. Document the client's refusal, using the client's own words, in quotes.
- C. Explain to the client that he must make decisions about accepting or refusing treatment while in the hospital.
- D. Request an assessment of the client's competency related to making decisions about advanced directives.
Correct Answer: B
Rationale: Respecting the client's autonomy, the nurse should document the refusal accurately, using the client's words, without forcing the issue.
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The nurse is caring for a client with suspected placenta previa. The nurse anticipates an order for which diagnostic test to confirm this finding?
- A. Manual cervical exam
- B. Transvaginal ultrasound
- C. Contraction stress test
- D. Nonstress test
Correct Answer: B
Rationale: Transvaginal ultrasound is the safest and most accurate method to confirm placenta previa, avoiding risky manual exams.
The nurse in the emergency department (ED) is caring for a 64-year-old male client.
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Nurses' Notes
1742: Client arrives at the emergency department via emergency medical services (EMS). He was skiing and crashed into a post and fell to the ground. Ski patrol assessed the client, and the client was confused and had no memory of the crash. Ski patrol reports that he was wearing a helmet and had a loss of consciousness for an unknown amount of time. On assessment, the client was alert and oriented to place and time but did not recall the events leading up to hospitalization, specifically the ski crash. Client states, “My head really hurts and I'm dizzy.” Reporting aching pain rated 8/10 on the Numerical Pain Scale. Reddish contusion on the client's forehead. Pupils were 2+, equal, and sluggishly reactive to light. Glasgow Coma Scale 14. Nose is midline and symmetrical. His speech was clear and articulate. Full range of motion in all extremities observed. Clear lung fields bilaterally. Radial pulse 2+ and irregular. Normoactive bowel sounds in all quadrants. No abdominal distention or pain. Vital signs: T 97.8° F (36.6° C), P 85, RR 15, BP 124/82, pulse oximetry reading 98% on room air. The client has a medical history of essential hypertension, generalized anxiety disorder, atrial fibrillation, and chronic back pain.
Home medications
• multivitamin (MVI) 1 tablet PO daily
• fluoxetine 20 mg PO daily
• biotin 100 mcg PO daily
• pantoprazole 40 mg PO daily
• warfarin 2.5 mg PO daily
• diltiazem controlled-release 120 mg PO daily
Complete the following sentence by choosing from the list of options. The nurse should prioritize obtaining an order for a ___ and ___ to better determine the extent of the client's injuries.
- A. radiograph (x-ray) of the head and neck
- B. electrocardiogram
- C. electroencephalogram
- D. computed tomography scan of the head
- E. hematocrit
- F. platelet count
- G. international normalized ratio
Correct Answer: D, G
Rationale: A CT scan of the head is critical to assess for brain injury, and INR is necessary due to warfarin use and bleeding risk.
The nurse is teaching a group of nursing students about the five rights of delegation. The nurse is correct to include that this involves the right
- A. intention
- B. alternative
- C. assessment
- D. task
Correct Answer: D
Rationale: The five rights of delegation include the right task, ensuring appropriate delegation.
The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?
- A. Assess the client for pain
- B. Assess the client's oxygen saturation
- C. Assess the client with the Glasgow Coma Scale (GCS)
- D. Assess the client's lung sounds
Correct Answer: B
Rationale: Restlessness and irritability post-sedation may indicate hypoxia. Assessing oxygen saturation is the priority to ensure airway and breathing stability.
The nurse has taught a client who has been ordered a high in phosphorus diet about appropriate food choices. Which of the following food choices by the client would indicate a correct understanding of the teaching?
- A. Leafy greens
- B. Garlic
- C. Nuts
- D. Butter
- E. Turkey
Correct Answer: C, E
Rationale: Nuts and turkey are high in phosphorus, suitable for a high-phosphorus diet.