Nokea
The nurse is caring for the following assigned clients. The nurse should immediately follow up with the client who has
- A. mechanical ventilation and the low-pressure alarm sounds.
- B. a new colostomy with refusal to participate in care.
- C. acute glomerulonephritis and has periorbital edema.
- D. atrial fibrillation with an irregular pulse.
Correct Answer: A
Rationale: A low-pressure ventilator alarm (D) suggests a leak or disconnection, risking airway compromise, requiring immediate follow-up. Colostomy refusal (A), periorbital edema (B), and irregular pulse in AF (C) are less urgent, as they are chronic or stable.
You may also like to solve these questions
The registered nurse (RN) supervises a licensed practical/vocational nurse (LPN). Which statement by the LPN/VN requires follow-up by the RN?
- A. I bathed the client already this morning'
- B. I passed out letters and packages to the clients this morning.'
- C. The client refused his prescribed valproic acid, so I snuck it into his food.'
- D. I will be joining the clients with their games today in the day room.'
Correct Answer: C
Rationale: Hiding medication in food (C) is unethical, unsafe, and violates client autonomy, requiring immediate RN follow-up. Bathing (A), distributing mail (B), and joining games (D) are within the LPN’s scope and do not require intervention.
The emergency department (ED) nurse is caring for an infant who is choking on a foreign object. On assessment, the infant is conscious and not making any noises. The nurse should immediately
- A. begin chest compressions at 100-120/minute.
- B. attempt a blind finger sweep in the mouth.
- C. perform abdominal thrusts.
- D. give five back blows and five chest thrusts.
Correct Answer: D
Rationale: For a conscious choking infant, five back blows followed by five chest thrusts (D) is the standard intervention to dislodge the foreign object, per pediatric advanced life support guidelines. Chest compressions (A) are for unresponsive infants, blind finger sweeps (B) risk pushing the object deeper, and abdominal thrusts (C) are not used in infants due to injury risk.
The charge nurse of a medical-surgical unit is informed that the nursing unit is short-staffed. Which task should the charge nurse delay in order to meet all client needs?
- A. Medication administration
- B. Daily baths
- C. Vital sign collection
- D. Hourly safety rounds
Correct Answer: B
Rationale: Daily baths (B) can be delayed as they are non-essential for immediate client safety. Medication administration (A), vital signs (C), and safety rounds (D) are critical for client care and cannot be postponed.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the RN? A client with
- A. chronic anemia requiring epoetin injections.
- B. a resolving pneumothorax with a chest tube.
- C. a tracheostomy requiring intermittent suctioning.
- D. septic shock requiring multiple interventions intravenous (IV) and vasopressors.
Correct Answer: D
Rationale: Septic shock requiring IV vasopressors (D) is a critical condition needing RN expertise for titration and monitoring. Anemia (A), resolving pneumothorax (B), and tracheostomy suctioning (C, C)) are more stable or routine, suitable for LPN care under supervision.
The nurse is caring for a newly admitted client. Which task can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Apply nasal cannula oxygen
- B. Remove a vascular access device that is not patent
- C. Perform venipuncture for laboratory work
- D. Obtain vital signs every four hours
Correct Answer: D
Rationale: Obtaining vital signs every four hours (D) is a routine task within the UAP’s scope. Applying oxygen (A), removing vascular access (B), and venipuncture (C) require nursing skills and judgment.