Nokea
The nurse is caring for assigned clients. The nurse should initially
- A. administer prescribed antibiotics to a client with bacterial meningitis.
- B. reposition a client with chronic back pain who reports pain rated 6/10 on the Numerical Rating Scale.
- C. remove a nitroglycerin prosthetic transdermal patch for a client with chronic angina.
- D. assess a client who had a coronary artery bypass grafting (CABG) three days ago and has a serum glucose of 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 3.9-6.1 mmol/L].
Correct Answer: A
Rationale: Antibiotics for bacterial meningitis (A) are critical to prevent rapid deterioration. Repositioning for pain (B), removing nitroglycerin patch (C), and assessing glucose of 135 (D) are less urgent.
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The nurse observes another nurse starting their shift under the influence of alcohol and decides not to report the nurse to the supervisor. Which ethical principle is the nurse violating?
- A. Confidentiality
- B. Nonmaleficence
- C. Justice
- D. Beneficence
Correct Answer: B
Rationale: Not reporting a nurse under the influence violates nonmaleficence (B), as it risks harm to clients due to impaired care. Confidentiality (A) is unrelated, justice (C) pertains to fairness, and beneficence (D) involves promoting good, which is secondary to preventing harm.
The nurse is planning client care. It would be a priority for the nurse to intervene if the client with
- A. osteomyelitis receiving intravenous (IV) antibiotics has a temperature of 103.4°F (39.7°C).
- B. viral hepatitis has persistent nausea and vomiting.
- C. septic shock has a mean arterial pressure of 56 mm Hg after a saline bolus.
- D. diverticulitis reports pain 7/10 on the Numerical Rating Scale.
Correct Answer: C
Rationale: A mean arterial pressure of 56 mm Hg in septic shock (C) indicates severe hypotension and organ hypoperfusion, requiring immediate intervention. High fever in osteomyelitis (A), nausea in hepatitis (B), and pain in diverticulitis (D) are serious but less immediately life-threatening.
The nurse is observing practices in the behavioral health unit. Which of the practices should the nurse question?
- A. Opening all client's postal packages prior to giving them to the client.
- B. Reviewing the process of how a client may lodge a formal complaint.
- C. Allowing clients to communicate over the telephone in a private area.
- D. Allowing clients who are involuntarily admitted to refuse prescribed medication(s).
Correct Answer: D
Rationale: Allowing involuntarily admitted clients to refuse medications (D) should be questioned, as court-ordered treatment may require compliance. Opening packages (A) ensures safety, complaint processes (B) are standard, and private calls (C) respect privacy.
The nurse manager reviews the results of a staff satisfaction survey. The feedback requests better engagement from the manager and staff involvement in unit-based decisions. Based on this feedback, the nurse manager plans to adjust their management style to
- A. democratic.
- B. transactional.
- C. laissez-faire.
- D. autocratic.
Correct Answer: A
Rationale: A democratic management style (A) involves staff in decision-making, addressing the feedback for better engagement and involvement. Transactional (B), laissez-faire (C), and autocratic (D) styles do not promote collaborative decision-making.
The nurse is caring for a client who is asking about advanced directives. Many documents fall under the category of an advanced directive. The nurse knows that one of the most common legal papers is called 'Durable Power of Attorney for Health Care' and works to:
- A. Review a person's personal preferences for medical care in the future.
- B. Authorize another person to make medical decisions for a person if they become unable to on their own.
- C. Assign a legal authority in making medical decisions while honoring the spoken word of the family.
- D. Define what care should be administered or withheld by health care professionals, no matter which medical facility the patient finds themselves in.
Correct Answer: B
Rationale: A Durable Power of Attorney for Health Care (B) authorizes a designated person to make medical decisions if the client is incapacitated. Reviewing preferences (A) describes a living will. Honoring family wishes (C) is not legally binding, and defining care across facilities (D) overstates its scope.