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The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
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The nurse in the emergency department (ED) is caring for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially
- A. developing a therapeutic rapport with the client.
- B. inserting a peripheral vascular access device.
- C. obtaining the client’s vital signs.
- D. collecting a serum lithium level on the client.
Correct Answer: B
Rationale: Inserting a peripheral vascular access device (B) is the initial priority in a lithium overdose to enable rapid administration of fluids or medications to stabilize the client. Vital signs (C) and lithium levels (D) follow, and rapport (A) is secondary to medical stabilization.
The nurse is planning a staff developmental conference about confidentiality. Which of the following scenarios should the nurse include as a violation of client confidentiality?
- A. Informing a visitor of the room number of a client admitted with pneumonia
- B. Telling a police officer who brought a client into the emergency department (ED) the urine drug screen results
- C. Notifying the pharmacist that a client is HIV positive and may have a potential drug interaction
- D. Informing local authorities that a client is suspected of being a victim of domestic violence
Correct Answer: B
Rationale: Sharing drug screen results with police (B) violates confidentiality without consent or legal mandate, per HIPAA. Room number (A) is not protected, HIV disclosure for care (C) is permitted, and reporting suspected abuse (D) is legally required.
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 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.
A client with a terminal illness asks the nurse about their prognosis. The nurse discusses the prognosis with the client, which the physician had previously divulged. Which ethical principle is the nurse demonstrating?
- A. Fidelity
- B. Confidentiality
- C. Beneficence
- D. Veracity
Correct Answer: D
Rationale: Discussing the prognosis truthfully (D) demonstrates veracity, the ethical principle of truth-telling. Fidelity (A) is keeping promises, confidentiality (B) protects information, and beneficence (C) promotes well-being, but veracity is most relevant here.