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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.
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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 registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints, which of the following tasks may the RN delegate to the LPN?
- A. Collect data on the client's skin integrity.
- B. Educate the client on the need for restraints.
- C. Initiate peripheral vascular access.
- D. Continually assess the client to determine if restraint use is necessary.
Correct Answer: A
Rationale: Collecting data on skin integrity (A) is within the LPN’s scope for monitoring restraint effects. Education (B) and ongoing restraint necessity assessment (D) require RN judgment, and initiating vascular access (C) may be outside LPN scope depending on state regulations.
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 observing unlicensed assistive personnel (UAP) care for assigned clients. Which of the following actions by the UAP would require the nurse to intervene? Select all that apply.
- A. While helping the client with an active range of motion, the UAP flexes and extends the client's elbow.
- B. Obtains orthostatic blood pressure by having the client stand first.
- C. Places the cane on the unaffected side of a client who had a stroke.
- D. Provides a hot foot soak for a client with diabetes mellitus.
- E. Obtains a urine culture from an indwelling urinary catheter.
Correct Answer: B, D, E
Rationale: Standing first for orthostatic BP (B) risks syncope, hot foot soaks for diabetes (D) risk burns due to neuropathy, and urine culture collection (E) requires sterile technique, all inappropriate for UAPs. Range of motion (A) and cane placement (C) are correct UAP tasks.
The nurse in the emergency department (ED) is caring for a client experiencing septic shock. The nurse should prioritize
- A. obtaining an order to insert an indwelling urethral catheter.
- B. monitoring the client's serum white blood cell count and lactic acid.
- C. establishing frequent blood pressure monitoring.
- D. monitoring the client's capillary blood glucose.
Correct Answer: C
Rationale: Frequent BP monitoring (C) is the priority in septic shock to assess hemodynamic stability and guide fluid/vasopressor therapy, per Surviving Sepsis guidelines. Catheter insertion (A), lab monitoring (B), and glucose checks (D) are secondary to immediate circulatory assessment.