Nokea
The nurse is caring for assigned clients. Which of the following activities should the nurse perform first?
- A. administer acetaminophen to a client with a temperature of 101.1°F (38.4°C)
- B. complete pin care for a client with a halo fixation device
- C. administer diazepam for a client with delirium tremens (DTs)
- D. insert an indwelling urinary catheter for a client with retention
Correct Answer: C
Rationale: Administering diazepam for delirium tremens (C) is the priority to prevent seizures and life-threatening complications. Fever treatment (A), pin care (B), and catheter insertion (D) are less urgent, as they address stable or less critical conditions.
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The nurse has been made aware of the following client situations. The nurse should first assess the client that
- A. is in a private room, and their stage III pressure ulcer tests positive for Pseudomonas aeruginosa.
- B. is three hours post-operative from the placement of an ileostomy and has an edematous reddened stoma.
- C. has type 2 diabetes mellitus and a morning blood glucose of 76 mg/dL (4.2 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L], and refuses breakfast.
- D. is awaiting an appendectomy and reports increased pain with coughing and is relieved by bending the right hip.
Correct Answer: B
Rationale: An edematous, reddened stoma post-ileostomy (B) may indicate ischemia, requiring immediate assessment. Pseudomonas ulcer (A), low glucose with meal refusal (C), and appendicitis pain (D) are less urgent.
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.
The nurse has administered prescribed medications to assigned clients. Which follow-up assessment requires immediate follow-up? A client who received prescribed
- A. intravenous hydromorphone for chronic back pain and is drowsy.
- B. intravenous metoclopramide for nausea and vomiting and now has involuntary movements of the jaw.
- C. intravenous dexamethasone for chronic bronchitis reporting perineal itching.
- D. nitroglycerin infusion for chest pain and reports a headache.
Correct Answer: B
Rationale: Involuntary jaw movements after intravenous metoclopramide (B) indicate extrapyramidal symptoms, a serious adverse reaction that may progress to dystonia, requiring immediate intervention like stopping the drug or administering an antidote (e.g., diphenhydramine). Drowsiness with hydromorphone (A), perineal itching with dexamethasone (C), and headache with nitroglycerin (D) are expected side effects and less urgent.
The nurse is discussing information about advanced directives with a client who expresses concerns, asking, 'What if I change my mind about what I want?' What approach would you use to respond to the client's care?
- A. Explain that the client would have to file a new witnessed document in order to make any changes.
- B. Discuss the need to be very sure about his preferences, as the living will is a binding legal document.
- C. Assure the client that he can change or revoke his advanced directives at any time.
- D. Advise the client that changes could not be made during this hospital stay.
Correct Answer: C
Rationale: Clients can change or revoke advance directives at any time (C), ensuring autonomy. New documents (A) may be needed but not restrictive, living wills are not unchangeable (B), and hospital stay (D) does not limit changes.
The nurse is reviewing leadership and management concepts with a student nurse. The student nurse demonstrates understanding if they made which of the following statements? Select all that apply.
- A. Battery is an intentional touching of another's body without the other's consent.'
- B. Assault is when the nurse makes a verbal or physical threat.'
- C. Unintentional torts include negligence and malpractice.'
- D. Defamation is presenting false credentials for employment.'
- E. Occurrence reports reduce the liability for a negligent tort.'
Correct Answer: A, B, C
Rationale: Battery (A) is non-consensual touching, assault (B) is a threat, and negligence/malpractice (C) are unintentional torts, all correct. Defamation (D) involves false statements harming reputation, not credentials, and occurrence reports (E) document but don’t reduce liability.