Nokea
The nurse is caring for a client admitted for an exacerbation of Meniere’s disease. Which of the following nursing interventions is of the highest priority when caring for this client?
- A. Determining if the client has experienced hearing loss.
- B. Initiating fall risk measures.
- C. Ensuring adherence to a low-sodium diet.
- D. Administering prescribed anticholinergic medications.
Correct Answer: B
Rationale: Initiating fall risk measures (B) is the highest priority in Meniere’s exacerbation due to vertigo, which poses an immediate safety risk. Hearing loss assessment (A), low-sodium diet (C), and medications (D) are important but secondary to preventing falls.
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The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply.
- A. drawing a line through the erroneous documentation.
- B. using correction tape and write over the error.
- C. writing over the error in darker ink.
- D. completely black out the error with a black marker.
- E. discarding the documentation in the trash and starting over.
- F. writing your initials, date, and time above the erroneous documentation with the word 'error.'
Correct Answer: A, F
Rationale: Correcting documentation errors involves drawing a single line through the error (A) and initialing, dating, and noting 'error' (F). Correction tape (B), writing over (C), blacking out (D), or discarding (E) are incorrect and violate documentation standards.
The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed
- A. intravenous hydromorphone for chronic back pain and is drowsy.
- B. intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw.
- C. intravenous dexamethasone for chronic bronchitis reporting perineal itching.
- D. nitroglycerin infusion for chest pain and reports a headache.
Correct Answer: B
Rationale: Involuntary jaw movements after intravenous metoclopramide (B) indicate extrapyramidal symptoms, a serious adverse reaction that may progress to dystonia, requiring immediate intervention like stopping the drug or administering an antidote (e.g., diphenhydramine). Drowsiness with hydromorphone (A), perineal itching with dexamethasone (C), and headache with nitroglycerin (D) are expected side effects and less urgent.
The nurse is caring for assigned clients. The nurse should prioritize seeing the client who
- A. has a chest tube attached to a closed-chest drainage system to treat a pneumothorax and reports increased dyspnea and dizziness.
- B. is being treated for acute pancreatitis and reports nausea and pain rated 6 on a scale of 0 (no pain) to 10 (severe pain).
- C. is being treated for pheochromocytoma and reports a headache, and most recent blood pressure is 149/84 mm Hg.
- D. has pneumonia with atelectasis and has had decreased breath sounds in the affected lobe.
Correct Answer: A
Rationale: Dyspnea and dizziness with a chest tube for pneumothorax (A) suggest complications like tube malfunction or hemothorax, requiring immediate assessment. Pancreatitis pain (B), headache with pheochromocytoma (C), and decreased breath sounds in pneumonia (D) are less urgent.
The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
- A. A 65-year-old male requiring sterile dressing changes.
- B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
- C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
- D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.
Correct Answer: B
Rationale: Assisting a client with ambulation (B) is a non-clinical task within the UAP’s scope. Sterile dressing changes (A), enteral feedings (C), and catheter specimen collection (D) require clinical judgment or training beyond UAP scope.
The nurse is caring for assigned clients. Which of the following activities should the nurse perform first?
- A. administer acetaminophen to a client with a temperature of 101.1°F (38.4°C)
- B. complete pin care for a client with a halo fixation device
- C. administer diazepam for a client with delirium tremens (DTs)
- D. insert an indwelling urinary catheter for a client with retention
Correct Answer: C
Rationale: Administering diazepam for delirium tremens (C) is the priority to prevent seizures and life-threatening complications. Fever treatment (A), pin care (B), and catheter insertion (D) are less urgent, as they address stable or less critical conditions.