Nokea
The nurse is caring for a client receiving nasal cannula oxygen and prescribed warfarin for venous thromboembolism (VTE) prevention. The unlicensed assistive personnel (UAP) informs the nurse that the client has a nose bleed. The nurse should initially
- A. have the unlicensed assistive personnel (UAP) apply petroleum water-soluble jelly to nares.
- B. review the most recent activated partial thromboplastin time (aPTT).
- C. assess the client for bruising and bleeding gums.
- D. obtain an order to humidify the oxygen.
Correct Answer: C
Rationale: Assessing for bruising and bleeding gums (C) evaluates the extent of bleeding risk on warfarin. Applying jelly (A) is inappropriate, reviewing aPTT (B) is secondary, and humidifying oxygen (D) is not urgent.
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The nurse is triaging phone calls at the physician’s office. The nurse should initially follow-up on the client who had
- A. cataract lens extraction one day ago and is reporting persistent nausea and vomiting.
- B. laparoscopic hysterectomy two days ago and is reporting pain with urination.
- C. ileostomy placement three days ago and is reporting that the stoma is swollen.
- D. total hip arthroplasty four days ago and refused physical therapy due to increased pain.
Correct Answer: A
Rationale: Persistent nausea and vomiting post-cataract surgery (A) suggest possible complications like increased intraocular pressure, requiring immediate follow-up. Dysuria (B), stoma swelling (C), and therapy refusal (D) are less urgent, as they are common or non-emergent.
The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply.
- A. Gloves being worn to pass out meal trays
- B. Sterile water used to irrigate nasogastric tubes
- C. Dedicated blood pressure cuffs for clients with contact precautions
- D. Sterile gloves used to provide perineal care during bed baths
- E. New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN)
Correct Answer: A, D
Rationale: Wearing gloves for meal tray distribution (A) and sterile gloves for perineal care (D) are excessive, as non-sterile gloves suffice, wasting resources. Sterile water for NG irrigation (B), dedicated cuffs for precautions (C), and new IV tubing for TPN (E) are appropriate practices.
The nurse reviews the nursing process with a group of students. Which of the following would demonstrate implementation? Select all that apply.
- A. Performing a sterile dressing change
- B. Interviewing the client about their social determinants
- C. Inputs risk for impaired skin integrity into the care plan
- D. Establishing a peripheral vascular access device
- E. Determining if the prescribed pain medication was effective
Correct Answer: A, D
Rationale: Performing a dressing change (A) and establishing IV access (D) are implementation actions, executing the care plan. Interviewing (B) is assessment, inputting risks (C) is planning, and determining medication effectiveness (E) is evaluation.
The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle?
- A. Autonomy
- B. Justice
- C. Paternalism
- D. Veracity
Correct Answer: A
Rationale: Informed consent demonstrates autonomy (A), allowing the client to make self-determined decisions, per ethical principles. Justice (B) ensures fairness, paternalism (C) involves decision-making for the client, and veracity (D) is truth-telling, none central to consent.
The nurse has attended a staff education program about sources of negligent lawsuits. It would indicate effective understanding if the nurse identifies which of the following is a source of a negligent lawsuit?
- A. The nurse documents care under another nurse's username and password
- B. The nurse takes pictures of a client's medical record and distributes them online
- C. The nurse does not notify the physician of a client's critical laboratory result
- D. The nurse treats their spouse in the acute care facility with prescribed medications
Correct Answer: A, B, C, D
Rationale: All options (A, B, C, D) are sources of negligent lawsuits: documenting under another’s credentials (A) is fraudulent, sharing medical records online (B) violates HIPAA, failing to report critical results (C) delays care, and treating a spouse with medications (D) breaches professional boundaries and scope of practice. Since the question implies multiple selections, all are correct.