Nokea
The nurse notes the patient care assistant looking through the personal items of the client with cancer. Which action should be taken by the registered nurse?
- A. Notify the police department as a robbery
- B. Report this behavior to the charge nurse
- C. Monitor the situation and note whether any items are missing
- D. Ignore the situation until items are reported missing
Correct Answer: B
Rationale: Reporting to the charge nurse ensures proper investigation.
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The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with methcillin resistant-staphylococcus aureas (MRSA)
- B. The client with diabetes
- C. The client with pancreatitis
- D. The client with Addison's disease
Correct Answer: A
Rationale: Clients with MRSA require contact precautions due to the highly contagious nature of the infection, necessitating a private room to prevent transmission to others.
The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should:
- A. Place tape completely around the extremity, with tape ends out of the client's vision
- B. Tell him that if he pulls out the IV, it will have to be restarted
- C. Slap the client's hand when he reaches toward the IV site
- D. Apply clove hitch restraints to the client's hands
Correct Answer: A
Rationale: Securing the IV with tape out of the client's vision minimizes tampering while avoiding restraints or inappropriate actions.
The nurse is caring for a client receiving Capoten (captopril). The nurse should be alert for adverse reactions to the drug, which include:
- A. Increased red cell count
- B. Decreased sodium level
- C. Decreased white cell count
- D. Increased calcium level
Correct Answer: C
Rationale: Captopril, an ACE inhibitor, can cause agranulocytosis, leading to a decreased white cell count, which should be monitored.
A nurse notes that clients of one surgeon have developed at least twice as many infections as clients of other surgeons on the unit. Which of the following is the most appropriate action?
- A. Report the physician to the hospital administration.
- B. Ask the physician why his rate of infections is so high.
- C. Report the observations to the infection control nurse.
- D. Say nothing as infection rates vary from time to time.
Correct Answer: C
Rationale: Reporting to the infection control nurse (C) initiates investigation and intervention. Reporting to administration (A) or confronting the physician (B) is premature, and ignoring the issue (D) is unsafe.
A client with chronic kidney disease (CKD) is being evaluated by the transplant team. The client's glomerular filtration rate (GFR) is 14 mL/min. This places the client in which stage of CKD?
- A. stage 1
- B. stage 5
- C. stage 4
- D. stage 2
Correct Answer: B
Rationale: GFR <15 mL/min indicates stage 5 CKD (end-stage renal disease), often requiring dialysis or transplant.