Nokea
The nurse is preparing to give an emergency sedative injection to an agitated client.Which action by the nurse is inappropriate?
- A. Placing a client in restraints without having a healthcare provider's order.
- B. Administering the medication to a client behind a closed curtain.
- C. Enlisting security personnel to assist with restraining the client.
- D. Informing a client that the medication being administered is a sedative.
Correct Answer: A
Rationale: Placing a client in restraints without having a healthcare provider's order is inappropriate for a nurse to do.
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The nurse is caring for a client who has only months predicted to live. The client avoids questions regarding plans for care.What is the next approach for the nurse to use when discussing end of life issues with the client?
- A. Ask questions in a vague, nonspecific format.
- B. Get the most difficult questions over with first.
- C. Begin with questions that are less sensitive in nature.
- D. Share personal values to put the client at ease.
Correct Answer: C
Rationale: Nurses who provide end of life care are trained to communicate in a way that is concise, yet sensitive. A personalized approach is often taken to meet the unique communication needs of each patient and to recognize when a person may be in pain or distressed.
The charge nurse is assisting a nurse in the admission process for a patient with multiple chronic conditions.Which action taken by the nurse demonstrates a breach of confidentiality to the charge nurse?
- A. Shares the health history with case manager.
- B. Discusses diagnoses with the physical therapist.
- C. Provides a list of food allergies to nutritional services.
- D. Requests military records by phone.
Correct Answer: D
Rationale: Requesting military records by phone without the patient's consent would be a breach of confidentiality.
An ulcerated foot peronet (FP) is to be implemented. The UAPs state they have not yet been educated on this before charging assignments.What action should the nurse take first?
- A. Send the UAP to be educated on how to care for a foot ulcer.
- B. Advise the UAP to wear gloves when caring for the FP.
- C. Instruct the UAP to start with basic wound care precautions.
- D. Ask the UAP which action they would take first and state why.
Correct Answer: A
Rationale: It is important for the UAP to receive proper education and training on how to care for a foot ulcer before being assigned to care for a client with this condition.
How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?
- A. Acute pain.
- B. Neuropathic pain.
- C. Visceral pain.
- D. Nociceptive pain.
Correct Answer: B
Rationale: The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain. Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system.
A client arrives at the emergency department (ED) with severe right upper quadrant pain.To assess the quality of the client's pain, which approach should the nurse use?
- A. Ask the client to describe the pain.
- B. Provide a numeric pain scale.
- C. Identify effective pain relief measures.
- D. Observe body language and movement.
Correct Answer: A
Rationale: To assess the quality of the client's pain, the nurse should ask the client to describe the pain. This will help the nurse to understand the characteristics of the pain and how it is affecting the client.