Nokea
The nurse obtains verbal prescriptions from the healthcare provider for an antianginal, telemetry, and STAT serum analysis for cardiac isoenzymes, after reading back the prescriptions to the healthcare provider of a client's upper gastric burning, left jaw pain, and nausea. Which intervention is most important for the nurse to implement?
- A. Initiate telemetry and assess the client's cardiac rhythm.
- B. Document description of nausea and administer the antiemetic.
- C. Submit electronic prescriptions to the pharmacy and laboratory.
- D. Obtain the client's 10-point score for radiating jaw pain.
Correct Answer: A
Rationale: Initiating telemetry addresses potential myocardial infarction, a priority given the client's symptoms.
You may also like to solve these questions
Several family members are visiting a client who had a myocardial infarction 4 days ago. The unlicensed assistive personnel (UAP) informs the nurse that one of the visitors is lying on the client's bed. Which action should the nurse implement?
- A. Discuss why visitors should not lie in the bed with the client.
- B. Notify the charge nurse that the visitor is lying on the client's bed.
- C. Explain that the client has the right to have a visitor lie on the bed.
- D. Instruct the UAP to ask the visitor to get off the client's bed.
Correct Answer: D
Rationale: Instructing the UAP to address the visitor maintains hygiene and safety efficiently.
An adult male is transferred from post anesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone 0.2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?
- A. Police department wants to be notified when the client is alert.
- B. Neurovascular assessments below the fracture are normal.
- C. No nausea or vomiting during the PACU recovery stay.
- D. The family is requesting a private room when one is available.
Correct Answer: B
Rationale: Normal neurovascular assessments are critical to ensure no complications post-surgery.
A newly hired unlicensed assistive personnel (UAP) expresses fear to the charge nurse about collecting a sputum specimen from a client who is HIV positive. Which action should the charge nurse take first?
- A. Provide the UAP with the infection control policy.
- B. Offer to assist the UAP with the collection of the specimen.
- C. Determine the UAP's knowledge about HIV transmission.
- D. Demonstrate the proper use of personal protective equipment.
Correct Answer: C
Rationale: Determining the UAP's knowledge about HIV transmission is the first action to address their fear, identify misconceptions, and provide targeted education.
The practical nurse (PN) is visiting a client who has stage four colon cancer and is receiving palliative home care. The client refuses to eat and sleeps most of the day. Which intervention should the nurse ask the PN to ensure the family is providing the client?
- A. Maintain in high Fowler's position.
- B. Report any change in urine color.
- C. Keep mucous membranes moist.
- D. Record the client's daily weight.
Correct Answer: C
Rationale: Keeping mucous membranes moist prevents discomfort and complications, a priority in palliative care.
The home health aide caring for a homebound hospice client calls to inform the nurse that the client has reported feeling constipated. Which task should the nurse instruct the home health aide to perform?
- A. Listen for the presence of bowel sounds.
- B. Administer a prescribed dose of a laxative.
- C. Teach the client about foods high in fiber.
- D. Assist the client to drink warm prune juice.
Correct Answer: D
Rationale: Assisting with warm prune juice is a safe, simple task within the aide's scope to relieve constipation.