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 nurse has obtained assistance from a licensed practical/vocational nurse (LPN/VN). Which tasks would be appropriate for the RN to delegate to the LPN/VN? Select all that apply.
- A. performing tracheostomy care
- B. initiate a transfusion of packed red blood cells
- C. flushing a peripherally inserted central catheter (PICC)
- D. inserting an indwelling urinary catheter
- E. administer enteral feedings via nasogastric tube
- F. titrate a medication
Correct Answer: A, C, D, E
Rationale: LPNs can perform tracheostomy care (A), flush PICCs (C), insert urinary catheters (D), and administer enteral feedings (E) per scope of practice. Initiating blood transfusions (B) and titrating medications (F) require RN judgment due to potential complications and dose adjustments.
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 has been made aware that the following clients require assistance. The nurse should first assist the client
- A. experiencing a flare-up of ulcerative colitis and has had 2 bloody bowel movements in the past hour.
- B. with a cerebral aneurysm, has developed nausea and vomiting.
- C. taking prescribed prednisone for an allergic reaction and reports indigestion.
- D. being treated for Bell's palsy and reports ringing in their ears.
Correct Answer: A
Rationale: Bloody bowel movements in ulcerative colitis (A) suggest active bleeding, requiring immediate assistance to prevent hypovolemia. Nausea with aneurysm (B), indigestion with prednisone (C), and tinnitus with Bell’s palsy (D) are less urgent.
The nurse is caring for a client requesting to leave against medical advice. The nurse barricades the client in their room because they feel that the client is not safe to go home. The nurse is demonstrating
- A. false imprisonment.
- B. malpractice.
- C. negligence.
- D. invasion of privacy.
Correct Answer: A
Rationale: Barricading a client (A) constitutes false imprisonment, as it unlawfully restricts their freedom. Malpractice (B) involves substandard care, negligence (C) requires harm from a breach of duty, and invasion of privacy (D) involves unauthorized disclosure.
The nurse is caring for a client who has been brought to the emergency department after a severe car accident. They require immediate life-saving surgery; however, they are unconscious and unable to consent to the operation. Which of the following is the best course of action?
- A. Ask a friend who was with the client to sign the consent form.
- B. Attempt calling a family member to obtain consent.
- C. Call the on-staff nursing supervisor and request a court order for the surgery.
- D. Immediately transport the client to the operating department without obtaining consent.
Correct Answer: D
Rationale: Implied consent applies for unconscious clients needing life-saving surgery (D), allowing immediate transport to the operating room. Friends (A) cannot legally consent, family contact (B) delays care, and court orders (C) are unnecessary in emergencies.