Nokea
The nurse is caring for assigned clients. The nurse should initially follow up on the client who
- A. is being treated for uterine fibroids and reports painful menstrual bleeding.
- B. has type II diabetes mellitus (type two) and has a capillary blood glucose of 124 mg/dL (6.882 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
- C. has emphysema and refused prescribed medications.
- D. is six hours postoperative following an abdominal aortic aneurysm repair and has no urine output.
Correct Answer: D
Rationale: No urine output six hours post-abdominal aortic aneurysm repair (D) suggests serious complications like renal artery occlusion or hypoperfusion, requiring immediate assessment. Painful bleeding (A), slightly elevated glucose (B), and medication refusal (C) are less urgent.
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A hospitalized client tells the nurse that she has a living will prepared and that her lawyer will be bringing the will to the hospital today for witness signatures. The client asks the nurse to help her obtain a witness for the will. Which of the following is the most appropriate response?
- A. I will sign as a witness to your signature.'
- B. Because it is a legal document, you will need to find a witness on your own.'
- C. Whoever is present at the time will sign as a witness for you.'
- D. I will contact the nursing supervisor for assistance regarding your request.'
Correct Answer: D
Rationale: Contacting the nursing supervisor (D) ensures compliance with legal witnessing requirements, as nurses may be restricted due to conflict of interest. Signing as a witness (A), leaving it to the client (B), or allowing anyone present (C) risks legal issues.
The nurse in the emergency department (ED) is caring for a client diagnosed with acute pancreatitis. The nurse should prioritize obtaining a prescription for
- A. intravenous fluids.
- B. ondansetron.
- C. the insertion of a nasogastric tube (NGT).
- D. fentanyl via patient-controlled analgesia.
Correct Answer: A
Rationale: IV fluids (A) are the priority in acute pancreatitis to correct hypovolemia and prevent organ failure, per clinical guidelines. Ondansetron (B), NGT (C), and fentanyl (D) address symptoms but are secondary to fluid resuscitation.
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. is being treated for acute glomerulonephritis (AGN) and has periorbital edema.
- B. has urolithiasis and reports persistent nausea.
- C. is receiving continuous bladder irrigation and reports the need to void.
- D. just returned from a hemodialysis session and reports dizziness.
Correct Answer: D
Rationale: Dizziness post-hemodialysis (D) suggests hypotension or fluid shifts, a life-threatening complication requiring immediate follow-up. Edema in AGN (A), nausea with urolithiasis (B), and voiding sensation with irrigation (C) are less urgent.
The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.
You are the nurse manager of the surgical acute care unit. You have noticed that several clients have almost been sent to the preoperative suite when they are not scheduled for a planned surgical procedure. Fortunately, no clients have gotten a 'wrong surgery' because this possible error was caught in time. What is your priority action as the nurse manager?
- A. Praise the staff for catching these near misses before a surgical error occurs.
- B. Investigate and explore this near miss.
- C. Investigate and explore this medical error.
- D. Report the nature and frequency of these medical errors to the State Department of Health.
Correct Answer: B
Rationale: Investigating and exploring the near miss (B) is the priority to identify root causes and prevent future errors. These are near misses, not medical errors (C, D), as no harm occurred. Praising staff (A) is supportive but secondary to addressing the systemic issue.