Nokea
The nurse is caring for the following assigned clients. It would be a priority for the nurse to assess the client
- A. being evaluated for chest pain and requesting an antacid for indigestion.
- B. reporting nervousness following the administration of albuterol.
- C. requesting pain medication for their chronic knee and back pain.
- D. awaiting discharge teaching on their insulin pump and glucometer.
Correct Answer: A
Rationale: Chest pain with indigestion (A) may indicate a cardiac event, requiring immediate assessment to rule out myocardial infarction. Nervousness from albuterol (B) is a common side effect, chronic pain (C) is less urgent, and discharge teaching (D) can wait.
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The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who
- A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C).
- B. has an indwelling urinary catheter and reports burning at the insertion site.
- C. has scant blood in their newly established ostomy pouch.
- D. has friends writing words on their fiberglass cast with different colored markers.
Correct Answer: A
Rationale: A fever of 101°F in Hirschsprung’s disease (A) suggests possible enterocolitis, a life-threatening complication requiring immediate follow-up. Catheter burning (B), scant ostomy blood (C), and cast writing (D) are less urgent, as they are expected or non-threatening.
The nurse is in an elevator and overhears two staff members discussing a client's condition. Which ethical principle does the nurse recognize may be potentially violated by this conversation?
- A. Beneficence
- B. Confidentiality
- C. Autonomy
- D. Veracity
Correct Answer: B
Rationale: Discussing a client’s condition in public violates confidentiality (B), as it breaches HIPAA and the client’s right to privacy. Beneficence (A), autonomy (C), and veracity (D) are unrelated to unauthorized disclosure of health information.
The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who is
- A. receiving albuterol via a nebulizer and reports feeling 'nervous'.
- B. awaiting a home healthcare referral following total hip arthroplasty.
- C. six hours post-op from a hysterectomy and is reporting nausea.
- D. reporting that their arm is 'sleeping' after having a cast for a fracture applied three hours ago.
Correct Answer: D
Rationale: Numbness ('sleeping' arm) post-cast application (D) suggests possible compartment syndrome or nerve compression, a surgical emergency requiring immediate follow-up. Nervousness from albuterol (A) is expected, home health referral (B) is non-urgent, and post-op nausea (C) is common but less critical.
The infection control nurse delegates tasks to staff to reduce hospital-acquired infections. Which task would be appropriate to delegate to the unlicensed assistive personnel (UAP)?
- A. Educate staff members on actions to reduce central line-associated bloodstream infections
- B. Demonstrating correct handwashing techniques to visitors
- C. Restocking personal protective equipment (PPE)
- D. Screening visitors for respiratory infections
Correct Answer: C
Rationale: Restocking PPE (C) is a non-clinical task within the UAP’s scope. Educating staff (A), demonstrating handwashing (B), and screening visitors (D) require clinical judgment or training, inappropriate for UAPs.
“ Initiate intravenous fluids to a client with anorexia nervosa
Administer venlafaxine to a client with persistent depressive disorder
Consult the social worker to begin discharge planning for a client
Obtain a blood sample to evaluate a client's lithium level”
The nurse has received the following prescriptions for newly admitted clients. The nurse should initially implement which of the following?
- A. initiate intravenous fluids to a client with anorexia nervosa.
- B. administer venlafaxine to a client with persistent depressive disorder.
- C. consult the social worker to begin discharge planning for a client.
- D. obtain a blood sample to evaluate a client's lithium level.
Correct Answer: A
Rationale: Initiating IV fluids for anorexia nervosa (A) is the priority to address life-threatening dehydration and electrolyte imbalances. Administering venlafaxine (B), consulting a social worker (C), and obtaining a lithium level (D) are less urgent, as they do not address immediate physiological threats.