Nokea
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.
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The nurse from the medical-surgical unit is calling a telephone report to the cardiac intensive care unit nurse regarding a client who is being transferred for a change in condition. Using the identification, situation, background, assessment, and recommendation (ISBAR) format, place the following communication steps in the order in which they should be performed, starting from first to last.
- A. He is a 56-year-old male admitted two days ago with community-acquired pneumonia. He has a medical history of diabetes mellitus and depression.
- B. His most recent vital signs were blood pressure 160/100, pulse 113, respirations 30, temperature 99, and oxygen saturation 89%. He is experiencing significant dyspnea and substernal chest pain radiating to the arm. The 12-lead electrocardiogram showed ST-elevation in two leads. Nasal cannula oxygen was applied, and 2 mg of IV morphine was given.
- C. Mr. Joe Smith is being transferred because he has trouble breathing and reports chest pain not relieved with nitroglycerin.
- D. Dr. Adams ordered a transfer because of confirmed myocardial infarction and to be treated with intravenous thrombolytics. When he arrives at the unit, he has an order for intravenous nitroglycerin infusion.
- E. I am the medical-surgical nurse calling to report about Mr. Joe Smith, the client being transferred with acute coronary syndrome.
Correct Answer: E, C, A, B, D
Rationale: Using ISBAR: 1. Identification (E) introduces the nurse and client. 2. Situation (C) outlines the current issue (chest pain, dyspnea). 3. Background (A) provides history. 4. Assessment (B) details vital signs and findings. 5. Recommendation (D) includes transfer orders and next steps.
The nurse has received the following prescriptions for newly admitted clients. The nurse should first administer which of the following?
- A. Enoxaparin to a client with a platelet count of 165,000 mm3 (165 × 10^9/L) [150-400 mm3, 130-380 × 10^9/L]
- B. Warfarin to a client with an international normalized ratio of 2.4 [0.9-1.2 seconds]
- C. Packed red blood cells to a client with a hemoglobin of 6.1 g/dL (3.78 mmol/L) [Female: 12-16 g/dL, Male: 14-18 g/dL, Female 115-155 g/L, Male 125-170 g/L]
- D. Regular insulin to a client with a blood glucose of 285 mg/dL (15.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]
Correct Answer: C
Rationale: Packed red blood cells for hemoglobin of 6.1 g/dL (C) is the priority to address severe anemia, which can cause tissue hypoxia. Enoxaparin (A) is safe with normal platelets, warfarin (B) is therapeutic at INR 2.4, and insulin (D) is urgent but less critical than severe anemia.
The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a
- A. collaborator
- B. team leader
- C. delegator
- D. manager
Correct Answer: A
Rationale: Collaborating with others across settings to achieve client-centered goals (A) defines the nurse’s role as a collaborator. Team leader (B) focuses on directing a group, delegator (C) assigns tasks, and manager (D) oversees operations, none of which fully capture this role.
The nurse is planning a staff education program about conflict resolution strategies. It is appropriate for the nurse to identify that compromising in a conflict may result in
- A. incomplete satisfaction of both parties’ concerns.
- B. appeasing an individual by self-sacrificing.
- C. suppression of thoughts and feelings.
- D. satisfaction of an individual’s interest regardless of the impact on others.
Correct Answer: A
Rationale: Compromising in conflict (A) often results in incomplete satisfaction for both parties, as each gives up something to reach agreement. Appeasing (B) involves self-sacrifice, suppression (C) avoids conflict, and individual satisfaction (D) reflects winning, not compromising.
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.