Nokea
The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit.
- A. Levofloxacin 750 mg IVPB Q12 hours
- B. 0.9% Saline 125 ml/hr
- C. Metoclopramide 10 mg IV Push Q8 hours
- D. Ketorolac 15 mg IV Push Q8 hours
Correct Answer: A
Rationale: Pneumonia in an elderly client can be particularly severe due to age-related immune system decline and potential for complications like acute respiratory distress syndrome (ARDS) and/or sepsis.
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The registered nurse (RN) and licensed practical/vocational nurse (LPN/VN) are caring for a client with an infected leg ulcer. Which task should the RN delegate to the LPN/VN?
- A. Obtain wound cultures during dressing changes
- B. Teach the client about high-protein food choices
- C. Assess the risk for further skin breakdown
- D. Initiate an outpatient wound care referral
Correct Answer: A
Rationale: Obtaining wound cultures during dressing changes (A) is a technical task within the LPN’s scope. Teaching (B), risk assessment (C), and referral initiation (D) require RN-level judgment and education skills.
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
- A. Establish continuous cardiac monitoring
- B. Obtain an order for a complete metabolic panel
- C. Obtain a prescription for acetaminophen (APAP)
- D. Apply a cool compress to the client's forehead
Correct Answer: A
Rationale: This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.
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 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.
A client has just been diagnosed with a terminal illness. She decides to execute a living will in the unit and asks the nurse to be the witness of the will. What is the most appropriate response by the nurse?
- A. I'm sorry, but under the law, we're not allowed to witness living wills.'
- B. Let me call the doctor. Maybe he can witness it for you.'
- C. Your family are the only people that can serve as witnesses.'
- D. Let me call the hospital attorney; he needs to be present when you sign your will.'
Correct Answer: A
Rationale: In many jurisdictions, nurses are restricted from witnessing living wills (A) due to potential conflicts of interest. Doctors (B) or attorneys (D) are not required, and family-only witnesses (C) is incorrect, as non-family can witness.