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The nurse is conducting a teaching session with the parents of a child newly diagnosed with asthma. The priority topic for the nurse to cover is
- A. how to use a peak flow meter.
- B. signs and symptoms of an asthma attack.
- C. the need to stay current with immunizations.
- D. community resources available for asthma management.
Correct Answer: B
Rationale: Recognizing signs and symptoms of an asthma attack (B) is critical for parents to initiate prompt intervention, preventing severe exacerbations. Peak flow meter use (A), immunizations (C), and community resources (D) are important but secondary to immediate safety education.
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The nurse enters a client's room and finds the client lying on the floor and appearing unresponsive. The nurse should initially
- A. initiate a code blue.
- B. assess the client's respiratory effort.
- C. assess the carotid pulse.
- D. shout the client's name.
Correct Answer: B
Rationale: Assessing respiratory effort (B) is the initial step for an unresponsive client to determine if breathing is present, guiding further action. Shouting (D), checking pulse (C), or initiating a code (A) follow assessment.
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. is repeatedly washing their hands.
- B. talking over others during group therapy.
- C. yelling and shouting at others.
- D. is voluntarily admitted and requesting discharge.
Correct Answer: C
Rationale: Yelling and shouting at others (C) indicates potential agitation or safety risk, requiring immediate follow-up to de-escalate and ensure unit safety. Hand washing (A), interrupting therapy (B), and discharge requests (D) are less urgent.
The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.
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 medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.