Nokea
The nurse is caring for assigned clients. The nurse should initially assess the client who has
- A. left pulmonary empyema, a temperature of 102.4°F (39.1°C), and a pulse of 104.
- B. gentle bubbling in the water seal chamber of their chest tube when exhaling.
- C. a right pleural effusion and has decreased tactile fremitus in the right lobe.
- D. pneumonia and has a pulse oximetry of 90% while on 4 liters of nasal cannula oxygen.
Correct Answer: A
Rationale: Fever (102.4°F) and tachycardia (104) in empyema (A) suggest worsening infection or sepsis, requiring immediate assessment. Chest tube bubbling (B) is normal, pleural effusion findings (C) are expected, and 90% saturation (D) is stable with oxygen.
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The nurse overhears another nurse state to a client 'If you do not behave, I will restrain you.' This statement demonstrates an example
- A. battery.
- B. libel.
- C. slander.
- D. assault.
Correct Answer: D
Rationale: Threatening restraint for behavior (D) is assault, a verbal threat of harm without physical contact, per legal definitions in healthcare. Battery (A) requires physical contact, libel (B) is written defamation, and slander (C) is spoken defamation, none of which apply.
The nurse is preparing to sign a client's surgical consent form after the physician has explained the procedure to the client and family. As the client signs the form, she comments 'I really didn’t understand most of what the doctor said, but I have to have this procedure, so I want to sign.' Which is the appropriate nursing action?
- A. Witness the document, as the client states she wants to sign it.
- B. Notify the physician or nursing supervisor.
- C. Call the OR to cancel the procedure and reschedule at a later date.
- D. Explain the information she did not understand.
Correct Answer: B
Rationale: Notifying the physician or nursing supervisor (B) ensures informed consent, a legal and ethical requirement, by addressing the client’s lack of understanding. Witnessing without clarification (A) violates consent principles, canceling the procedure (C) is premature, and explaining as a nurse (D) may exceed the nurse’s role, as the physician should clarify procedure details.
A nurse is caring for a client who is admitted to the emergency department with suspected rhabdomyolysis. Which of the following interventions should the nurse anticipate implementing initially for this client?
- A. Administering intravenous fluids
- B. Monitoring the client’s liver enzymes
- C. Administering corticosteroids
- D. Initiating prophylactic antibiotic therapy
Correct Answer: A
Rationale: Intravenous fluids (A) are the initial intervention for rhabdomyolysis to prevent kidney damage by flushing myoglobin and maintaining urine output. Monitoring liver enzymes (B), corticosteroids (C), and antibiotics (D) are not primary interventions for this condition.
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 has received the following prescriptions for newly admitted clients. Which prescription should the nurse administer first?
- A. Aspirin to a client experiencing an acute myocardial infarction
- B. Lisinopril to a client with essential hypertension
- C. Risperidone to a client with schizophrenia
- D. Levodopa-carbidopa to a client with Parkinson's disease
Correct Answer: A
Rationale: Aspirin for acute myocardial infarction (A) is the priority to reduce thrombus formation and mortality, per ACS guidelines. Lisinopril (B), risperidone (C), and levodopa-carbidopa (D) address chronic conditions and are less urgent.