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The nurse is caring for a client who fell off the ladder. The client reports numbness in his lower extremities. The nurse should initially
- A. assess the client for lacerations
- B. evaluate the range of motion of the client's neck
- C. provide cervical spine stabilization
- D. assess the client's range of motion in the lower extremities
Correct Answer: C
Rationale: Numbness in lower extremities suggests spinal cord injury, requiring immediate cervical spine stabilization (C) to prevent further damage. Assessing lacerations (A), neck range of motion (B), or lower extremity motion (D) risks exacerbating injury.
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The nurse is caring for a client who expresses feeling self-conscious about their hair and states they would like to wash it before undergoing diagnostic tests and procedures. How should the nurse prioritize the client's care?
- A. Offer the client a cap or scarf to cover their hair and suggest washing it after the diagnostic tests are complete.
- B. The nurse should schedule the testing and meal planning first and complete hygiene as time permits.
- C. Perform the dressing changes first, schedule testing, counsel, and complete hygiene last.
- D. Arrange to wash the client's hair first, perform hygiene, and then complete the diagnostic testing and counseling.
Correct Answer: A
Rationale: Offering a cap/scarf and suggesting washing later (A) addresses the client’s emotional needs while prioritizing timely diagnostics, ensuring medical care is not delayed. Scheduling tests first (B), prioritizing dressings (C), or washing hair first (D) either delays care or ignores efficiency.
The nurse is developing a staff in-service on negligence. A participant demonstrates correct understanding by identifying which elements must be met in a negligence lawsuit? Select all that apply.
- A. Duty owed
- B. Breach of duty owed
- C. Causation
- D. Harm or damages
- E. Beneficence
Correct Answer: A, B, C, D
Rationale: Negligence requires duty owed (A), breach of duty (B), causation (C), and harm or damages (D). Beneficence (E) is an ethical principle, not a legal element of negligence.
The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the licensed practical/vocational nurse (LPN/VN) would require follow-up from the charge nurse?
- A. Obtaining an occult stool sample for a client with ulcerative colitis.
- B. Assessing a newly admitted client with chest pain.
- C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus.
- D. Providing pin care for a client with external fixation of the wrist.
Correct Answer: B
Rationale: Assessing a new client with chest pain (B) requires RN-level judgment due to potential life-threatening conditions, necessitating follow-up if delegated to an LPN. Stool sample collection (A), reinforcing teaching (C), and pin care (D) are within LPN scope.
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 is caring for assigned clients. The nurse should initially follow up on the client who
- A. has a basilar skull fracture and has bruises under their eyes.
- B. had a craniotomy and has a change in the Glasgow coma scale (GCS) from 13 to 11 in the last hour.
- C. has amyotrophic lateral sclerosis (ALS) and is requesting to have resuscitation efforts withheld.
- D. has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness.
Correct Answer: B
Rationale: A GCS drop from 13 to 11 post-craniotomy (B) indicates neurological deterioration, possibly from hematoma, requiring immediate follow-up. Bruises with skull fracture (A), ALS DNR request (C), and GBS weakness (D) are less urgent, though GBS needs monitoring.