Nokea
The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who
- A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C).
- B. has an indwelling urinary catheter and reports burning at the insertion site.
- C. has scant blood in their newly established ostomy pouch.
- D. has friends writing words on their fiberglass cast with different colored markers.
Correct Answer: A
Rationale: A fever of 101°F in Hirschsprung’s disease (A) suggests possible enterocolitis, a life-threatening complication requiring immediate follow-up. Catheter burning (B), scant ostomy blood (C), and cast writing (D) are less urgent, as they are expected or non-threatening.
You may also like to solve these questions
The nurse has been made aware that the following clients require assistance. The nurse should first assist the client
- A. experiencing a flare-up of ulcerative colitis and has had 2 bloody bowel movements in the past hour.
- B. with a cerebral aneurysm, has developed nausea and vomiting.
- C. taking prescribed prednisone for an allergic reaction and reports indigestion.
- D. being treated for Bell's palsy and reports ringing in their ears.
Correct Answer: A
Rationale: Bloody bowel movements in ulcerative colitis (A) suggest active bleeding, requiring immediate assistance to prevent hypovolemia. Nausea with aneurysm (B), indigestion with prednisone (C), and tinnitus with Bell’s palsy (D) are less urgent.
The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.
The infection control nurse delegates tasks to staff to reduce hospital-acquired infections. Which task would be appropriate to delegate to the unlicensed assistive personnel (UAP)?
- A. Educate staff members on actions to reduce central line-associated bloodstream infections
- B. Demonstrating correct handwashing techniques to visitors
- C. Restocking personal protective equipment (PPE)
- D. Screening visitors for respiratory infections
Correct Answer: C
Rationale: Restocking PPE (C) is a non-clinical task within the UAP’s scope. Educating staff (A), demonstrating handwashing (B), and screening visitors (D) require clinical judgment or training, inappropriate for UAPs.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? A client with
- A. chronic anemia requiring epoetin injections.
- B. a resolving pneumothorax with a chest tube.
- C. a tracheostomy requiring intermittent suctioning.
- D. septic shock requiring multiple interventions intravenous (IV) and vasopressors.
Correct Answer: D
Rationale: Septic shock requiring IV vasopressors (D) is a critical condition needing RN expertise for titration and monitoring. Anemia (A), resolving pneumothorax (B), and tracheostomy suctioning (C, C)) are more stable or routine, suitable for LPN care under supervision.
The nurse is caring for a client who has been brought to the emergency department after a severe car accident. They require immediate life-saving surgery; however, they are unconscious and unable to consent to the operation. Which of the following is the best course of action?
- A. Ask a friend who was with the client to sign the consent form.
- B. Attempt calling a family member to obtain consent.
- C. Call the on-staff nursing supervisor and request a court order for the surgery.
- D. Immediately transport the client to the operating department without obtaining consent.
Correct Answer: D
Rationale: Implied consent applies for unconscious clients needing life-saving surgery (D), allowing immediate transport to the operating room. Friends (A) cannot legally consent, family contact (B) delays care, and court orders (C) are unnecessary in emergencies.