Nokea
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. has atrial fibrillation and a heart rate of 112/minute.
- B. has glomerulonephritis with a blood pressure of 137/86 mm Hg.
- C. is receiving amphotericin B, and the most recent temperature is 100.4°F (38°C).
- D. has chronic obstructive pulmonary disease (COPD) with an oxygen saturation of 91% on room air.
Correct Answer: A
Rationale: Atrial fibrillation with a heart rate of 112/minute (A) indicates a rapid ventricular response, risking hemodynamic instability or stroke, requiring immediate rate control. Glomerulonephritis with normal BP (B), mild fever with amphotericin (C), and COPD with 91% saturation (D) are less urgent, as they are stable or expected.
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A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
- A. Document the refusal
- B. Notify the primary healthcare provider (PHCP)
- C. Review the client's most recent platelet count
- D. Inquire with the client about the refusal
Correct Answer: D
Rationale: Inquiring about the refusal (D) allows the nurse to understand the client’s concerns, provide education, and address barriers, promoting informed decision-making. Documenting (A) and notifying the provider (B) are secondary steps, and reviewing platelet count (C) is irrelevant without addressing the refusal first.
[Orders ]
olanzapine 2.5 mg by mouth daily
obtain daily weights
12-lead electrocardiogram
consult nutritional services
The nurse is reviewing the physician orders for a client admitted with anorexia nervosa reporting weakness and abdominal distention. The nurse should prioritize:
- A. administering olanzapine.
- B. consulting nutritional services.
- C. performing the 12-lead electrocardiogram.
- D. weighing the client.
Correct Answer: C
Rationale: The client with anorexia nervosa reporting abdominal distention and weakness is concerning for hypokalemia. The nurse should prioritize performing the 12-lead electrocardiogram because cardiovascular collapse may occur if the client's physical symptoms go unrecognized and untreated. Additional testing is required, including a complete metabolic panel and magnesium level. Features of hypokalemia on the electrocardiogram include U-wave development, ST depression, and shallow, flat, or inverted T wave.
The registered nurse (RN) is working with a licensed practical/vocational nurse (LPN/VN). Which client assignment should the RN delegate to the LPN? A client
- A. immediately post-operative following a thyroidectomy.
- B. with a paralytic ileus requiring the management of a nasogastric tube.
- C. receiving intravenous magnesium sulfate for status asthmaticus.
- D. with a hypertensive crisis requiring initiation of intravenous nicardipine.
Correct Answer: B
Rationale: Managing a nasogastric tube for paralytic ileus (B) is within the LPN’s scope for stable clients. Post-thyroidectomy (A), magnesium sulfate (C), and hypertensive crisis (D) require RN monitoring due to critical risks.
The nurse is providing discharge instructions to a client who speaks a language different from the nurse's. The client's family members are present, and they speak English. Which action by the nurse is the most appropriate to ensure effective communication during the discharge process?
- A. Use a smartphone translation app to convey the instructions to the client.
- B. Provide written material in the client's language and provide oral instructions in English.
- C. Request an interpreter from the hospital's language services to assist with the discharge instructions.
- D. Summarize the instructions in basic English and have the family members relay the information to the client.
Correct Answer: C
Rationale: Using a professional interpreter (C) ensures accurate communication, adhering to legal and ethical standards for discharge teaching. Smartphone apps (A) are unreliable, written material with English oral instructions (B) is ineffective, and relying on family (D) risks misinterpretation.
The nurse manager plans to reduce supply-related costs within the nursing unit. While evaluating nursing staff, which observation demonstrates an ineffective use of resources? Select all that apply.
- A. Gloves being worn to pass out meal trays
- B. Sterile water used to irrigate nasogastric tubes
- C. Dedicated blood pressure cuffs for clients with contact precautions
- D. Sterile gloves used to provide perineal care during bed baths
- E. New intravenous (IV) tubing with each bag of total parenteral nutrition (TPN)
Correct Answer: A, D
Rationale: Wearing gloves for meal tray distribution (A) and sterile gloves for perineal care (D) are excessive, as non-sterile gloves suffice, wasting resources. Sterile water for NG irrigation (B), dedicated cuffs for precautions (C), and new IV tubing for TPN (E) are appropriate practices.