Nokea
The nurse overhears an unlicensed assistive personnel (UAP) shout at a client, 'you will have to get a feeding tube if you do not start eating more at mealtimes.' The nurse recognizes that the UAP has Select all that apply.
- A. committed battery.
- B. engaged in unprofessional conduct.
- C. committed assault.
- D. been negligent.
- E. demonstrated libel.
Correct Answer: B, C
Rationale: Shouting and threatening a feeding tube (B, C) constitutes unprofessional conduct (B) and assault (C), a verbal threat of harm. Battery (A) requires physical contact, negligence (D) involves failure of duty, and libel (E) is written defamation, none of which apply.
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The risk manager reviews an incident report completed by a nurse regarding a client’s fall. Which finding in the report demonstrates inappropriate documentation?
- A. The client’s explanation of the event.
- B. Subjective factors preceding the fall.
- C. Any injuries sustained as a result of the fall.
- D. The names of all witnesses present.
Correct Answer: B
Rationale: Subjective factors (B) are inappropriate in incident reports, as they may include opinions rather than objective facts. The client’s explanation (A), injuries (C), and witness names (D) are factual and appropriate to document.
The emergency department (ED) nurse cares for a client with diabetes mellitus (type one) with diabetic ketoacidosis (DKA). Which assessment finding requires immediate follow-up?
- A. Pulse 112/minute
- B. Nausea and vomiting
- C. Respiratory rate 21/minute
- D. Blood glucose 299 mg/dL (16.5 mmol/L) [70-110 mg/dL (4-6 mmol/L)]
Correct Answer: B
Rationale: Nausea and vomiting in DKA (B) can worsen dehydration and electrolyte imbalances, requiring immediate follow-up. Tachycardia (A) and tachypnea (C) are expected, and glucose of 299 (D) is consistent with DKA but less urgent.
The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.
A nurse is caring for a client who speaks a language different from the healthcare team. Which action by the nurse best ensures effective communication with the client?
- A. Using family members as interpreters.
- B. Utilizing a professional interpreter provided by the healthcare facility.
- C. Attempting to communicate using basic words and gestures.
- D. Referring the client to a language class for healthcare professionals.
Correct Answer: B
Rationale: A professional interpreter (B) ensures accurate, confidential communication, per Joint Commission standards. Family interpreters (A) risk bias, gestures (C) are unreliable, and language classes (D) are impractical for immediate needs.
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.