Nokea
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
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The nurse is educating staff on adult basic life support. It would be appropriate to include which of the following? Select all that apply.
- A. Carotid pulse check should not take more than 20 seconds.
- B. The rate of chest compressions should be 100-120 per minute.
- C. Chest compression depth should be 2 inches on the center breastbone.
- D. Chest tube insertion should be prepared after five minutes of CPR.
- E. Early defibrillation is essential in the survival of ventricular fibrillation.
Correct Answer: B, E
Rationale: Chest compression rate of 100-120/minute (B) and early defibrillation for ventricular fibrillation (E) are correct per AHA guidelines. Pulse check is ≤10 seconds (A), depth is ~2.4 inches (C), and chest tube insertion (D) is not part of BLS.
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 in the emergency department (ED) has a client with suspected septic shock. The priority intervention for this client is to
- A. establish a peripheral vascular access device.
- B. obtain the prescribed consult with infectious disease.
- C. provide frequent updates regarding the client's care.
- D. perform a physical assessment for the potential source of infection.
Correct Answer: A
Rationale: Establishing a peripheral vascular access device (A) is the priority in septic shock to enable rapid fluid and medication administration. Infectious disease consult (B), care updates (C), and source assessment (D) follow after stabilizing access.
The nurse is caring for a 13-year-old in the pediatric unit with a left-side below-the-knee cast. The client reports pain and numbness in the foot. The nurse notes that the toes of the left foot are cold. Which of the following actions should the nurse take first?
- A. Remove the cast.
- B. Have the child ambulate.
- C. Notify the physician.
- D. Elevate the leg on two pillows.
Correct Answer: C
Rationale: Pain, numbness, and cold toes in a casted limb (C) suggest compartment syndrome, a medical emergency requiring immediate physician notification to prevent tissue damage. Removing the cast (A), ambulating (B), or elevating (D) without orders could worsen the condition.
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.