Nokea
The nurse is planning to interview a client interested in establishing care with a primary healthcare provider (PHCP). The nurse should initially
- A. obtain the client's vital signs.
- B. identify the client's chief complaint.
- C. provide a private area for the interview.
- D. inquire about the client's allergies.
Correct Answer: C
Rationale: Providing a private area (C) ensures confidentiality and comfort, the initial step for an interview. Chief complaint (B), allergies (D), and vital signs (A) follow after establishing privacy.
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The nurse is caring for a client who has just returned from receiving a hemodialysis treatment. It would require immediate follow-up by the nurse if the client has
- A. a temperature (T) of 99.4°F (37.4°C).
- B. restlessness and a headache.
- C. weight loss of 3 kilograms (6.6 pounds).
- D. persistent fatigue.
Correct Answer: B
Rationale: Restlessness and headache post-hemodialysis (B) suggest disequilibrium syndrome or hypotension, critical complications requiring immediate follow-up. Mild fever (A), weight loss (C), and fatigue (D) are expected or less urgent.
The nurse manager plans to develop a unit-based council to assist in decision-making. The nurse manager is demonstrating which leadership style?
- A. Authoritative
- B. Democratic
- C. C. Laissez-Faire
- D. D. Transactional
Correct Answer: B
Rationale: A unit-based council reflects a democratic leadership style (B), involving staff in decision-making. Authoritative (A) is directive, laissez-faire (C) is passive, and transactional (D) focuses on rewards and tasks, not shared governance.
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. is being treated for acute glomerulonephritis (AGN) and has periorbital edema.
- B. has urolithiasis and reports persistent nausea.
- C. is receiving continuous bladder irrigation and reports the need to void.
- D. just returned from a hemodialysis session and reports dizziness.
Correct Answer: D
Rationale: Dizziness post-hemodialysis (D) suggests hypotension or fluid shifts, a life-threatening complication requiring immediate follow-up. Edema in AGN (A), nausea with urolithiasis (B), and voiding sensation with irrigation (C) are less urgent.
The registered nurse (RN) is planning client care assignments. Which client would be appropriate to assign to the licensed practical/vocational nurse (LPN/VN)? A client
- A. with Guillain-Barre syndrome client reporting dyspnea while at rest.
- B. with stage 3 and 4 pressure injuries present in the sacral area.
- C. 2 hours postoperative total laryngectomy.
- D. awaiting a referral for outpatient diabetic support services.
Correct Answer: D
Rationale: A client awaiting a referral for diabetic support services (D) is stable and suitable for LPN care, involving coordination within scope. Guillain-Barré syndrome with dyspnea (A), severe pressure injuries (B), and recent laryngectomy (C) require RN assessment due to critical or complex needs.
The nurse is preparing to insert an indwelling urinary catheter. Which action may be delegated to the unlicensed assistive personnel (UAP)?
- A. Set up the sterile field
- B. Palpate the bladder for distention
- C. Explain the procedure to the client
- D. Place the urinary catheter kit at the bedside
Correct Answer: D
Rationale: Placing the catheter kit at the bedside (D) is a non-clinical task suitable for a UAP. Setting up a sterile field (A), palpating the bladder (B), and explaining the procedure (C) require clinical judgment or training beyond UAP scope.