Nokea
The nurse is preparing medications for the shift. Which of the following clients should the nurse prioritize for immediate medication administration?
- A. Digoxin to a client with atrial fibrillation
- B. Furosemide to a client with congestive heart failure
- C. Magnesium sulfate to a client with Torsades de pointes
- D. Labetalol to a client with a blood pressure of 160/100 mmHg
Correct Answer: C
Rationale: Magnesium sulfate for Torsades de pointes (C) is the priority to stabilize life-threatening ventricular arrhythmias, per ACLS guidelines. Digoxin (A), furosemide (B), and labetalol (D) address less acute conditions.
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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 LPN?
- A. A client requiring assistance picking out low potassium foods.
- B. A client requesting to leave the facility against medical advice (AMA).
- C. A client needing several prescriptions called into the local pharmacy.
- D. A client requesting breakthrough intravenous push (IV) pain medicine.
Correct Answer: A
Rationale: Assisting with low potassium food choices (A) is within the LPN’s scope, involving reinforcement of dietary teaching. AMA requests (B) and IV pain medication (D) require RN judgment, and calling prescriptions (C) may involve complex coordination.
Which statement about the placebo is the most accurate?
- A. Placebos are often used to determine if the client's reports of pain are valid.
- B. Placebos are not used in research because the client has not given consent.
- C. Placebo use is unethical unless they are used in research with the subject's consent.
- D. Placebo use is illegal according to all states and the federal government.
Correct Answer: C
Rationale: Placebo use is ethical in research with informed consent (C), as it ensures transparency. Using placebos to validate pain (A) is unethical, placebos are used in research (B), and they are not illegal (D).
An advantage of mutual pretense at the end of life for the client is that it allows the client:
- A. To fully employ the ego defense mechanism of denial at the end of life.
- B. To exercise control over loved ones when they are at the end of life.
- C. To fully employ the ego defense mechanism of projection at the end of life.
- D. To preserve a degree of dignity and privacy at the end of life.
Correct Answer: D
Rationale: Mutual pretense allows clients to preserve dignity and privacy (D) by avoiding open acknowledgment of death, maintaining emotional comfort. Denial (A) and projection (C) are not the primary mechanisms, and control over loved ones (B) is not the focus.
The nurse is preparing to discharge clients from the nursing unit. Which client has the greatest need to be referred for outpatient community services?
- A. A client newly diagnosed with skin cancer that lives with family.
- B. A client recovering from a stroke and is discharged to inpatient rehab.
- C. A client who is homeless and has a substance use disorder.
- D. A client leaving against medical advice for the treatment of cellulitis.
Correct Answer: C
Rationale: A homeless client with substance use disorder (C) has the greatest need for outpatient services to address social determinants and prevent relapse. Skin cancer with family (A), stroke rehab (B), and AMA cellulitis (D) have alternative support or less urgent needs.
The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is
- A. 16 weeks of gestation and reports a fluttering sensation.
- B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool.
- C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet.
- D. 38 weeks of gestation and reports lower back pain that increases with walking.
Correct Answer: B
Rationale: Bright red blood in the stool at 30 weeks gestation (B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (A) is normal quickening, leg cramps and swelling at 28 weeks (C) are common, and back pain at 38 weeks (D) is typical, all less urgent.