Nokea
The nurse is caring for a client who reports that another nurse hit them. The nurse should take which action?
- A. Inquire with the nurse if this incident occurred
- B. Assess the client for any prior episodes of abuse
- C. Determine if the client has any cognitive impairments
- D. Report the client's concern to the nursing supervisor
Correct Answer: D
Rationale: Reporting the allegation to the nursing supervisor (D) is the priority to ensure proper investigation and client safety, per facility policy. Inquiring directly (A), assessing prior abuse (B), or checking cognition (C) risks bias or delays formal action.
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The registered nurse (RN) assigns client care to a licensed practical/vocational nurse (LPN/VN). Which of the following clients should the RN assign to the LPN? Select all that apply. A client
- A. requiring an assessment of their current prescribed medications.
- B. needing a nasogastric tube (NGT) for enteral feedings.
- C. with an insulin pump and is unsure of how to load the insulin.
- D. with unstable blood pressure following adrenalectomy.
- E. requiring airborne isolation and bronchodilators via an inhaler.
Correct Answer: B, E
Rationale: Administering enteral feedings via NGT (B) and bronchodilators via inhaler (E) are within the LPN’s scope for stable clients. Medication assessment (A), insulin pump teaching (C), and unstable BP post-adrenalectomy (D) require RN-level judgment due to complexity or instability.
A licensed practical/vocational (LPN/VN) nurse assists the behavioral health unit's registered nurse (RN). Which task can the RN appropriately delegate to the LPN/VN?
- A. Alcohol withdrawal screening on a client going through detoxification
- B. Medication administration to a client with a nasogastric tube
- C. Suicide assessment on a newly admitted client
- D. Educating a client on newly prescribed citalopram
Correct Answer: B
Rationale: Medication administration via nasogastric tube (B) is within the LPN’s scope. Alcohol withdrawal screening (A), suicide assessment (C), and education on new medications (D) require RN-level assessment and teaching skills.
The nurse is caring for a client recovering from hip surgery who needs to regain strength to climb the flight of stairs leading to their bedroom at home. The nurse should recommend a referral to a
- A. physical therapist (PT).
- B. nutritionist.
- C. C. case manager.
- D. D. occupational therapist (OT).
Correct Answer: A
Rationale: A physical therapist (A) specializes in improving strength and mobility, essential for stair climbing post-hip surgery. Nutritionists (B) focus on diet, case managers (C) coordinate care, and occupational therapists (D) address daily living activities.
The nurse is planning a staff development conference about changing the process of how clients are seen at a clinic to a first come, first served basis. This proposed change will model which ethical principle?
- A. Nonmaleficence
- B. Veracity
- C. Paternalism
- D. Justice
Correct Answer: D
Rationale: A first-come, first-served process (D) models justice by ensuring fair and equitable access to care based on arrival time. Nonmaleficence (A), veracity (B), and paternalism (C) do not apply to this resource allocation change.
The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
- A. has a closed-chest drainage system and has redness at the insertion site.
- B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour.
- C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.
Correct Answer: D
Rationale: Hypotension (100/58 mm Hg) in ischemic stroke (D) suggests hemodynamic instability, risking cerebral perfusion and requiring immediate follow-up. Redness at chest tube site (A), bloody stools in ulcerative colitis (B), and mild headache in concussion (C) are concerning but less immediately life-threatening.