Nokea
The nurse plans care for a client with a vancomycin-resistant enterococcus (VRE) infection. Which action should the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Place gowns and gloves outside of the client’s room
- B. Educate the client and family members on ways to prevent transmission of VRE
- C. Affix a droplet precautions sign on the client’s door
- D. Validate the client’s understanding on hand hygiene
Correct Answer: A
Rationale: Placing gowns and gloves outside the room (A) is a non-clinical task within the UAP’s scope. Education (B), signage for droplet precautions (C, incorrect for VRE), and validating understanding (D) require clinical judgment and are RN/LPN responsibilities.
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The nurse is admitting a client who is blind and deaf. The nurse should prioritize which action?
- A. Review the plan of care with the client
- B. Communicate with the nursing supervisor with any safety concerns
- C. C. Update the client on the social activities
- D. D. Provide a safe environment for the client
Correct Answer: D
Rationale: Providing a safe environment (D) is the priority for a blind and deaf client to prevent injury, using tactile communication and clear pathways. Reviewing care plans (A), addressing concerns (B), or social updates (C) are secondary to immediate safety.
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. is being treated for acute glomerulonephritis (AGN) and has periorbital edema.
- B. has urolithiasis and reports persistent nausea.
- C. is receiving continuous bladder irrigation and reports the need to void.
- D. just returned from a hemodialysis session and reports dizziness.
Correct Answer: D
Rationale: Dizziness post-hemodialysis (D) suggests hypotension or fluid shifts, a life-threatening complication requiring immediate follow-up. Edema in AGN (A), nausea with urolithiasis (B), and voiding sensation with irrigation (C) are less urgent.
The nurse has been made aware of the following client situations. The nurse should first follow up with the client
- A. receiving a chemotherapy infusion who reports nausea and vomiting.
- B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain.
- C. being treated for aplastic anemia and has a temperature of 101.1°F (38.4°C).
- D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.
Correct Answer: C
Rationale: A fever in a client with aplastic anemia (C) indicates potential infection, a life-threatening complication due to low white blood cells, requiring immediate attention. Nausea from chemotherapy (A), hematuria with kidney disease (B), and TB with a mask (D) are less urgent.
The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)?
- A. Elevated amylase result in a client diagnosed with acute pancreatitis
- B. Elevated white blood cell (WBC) count in a client with an infected leg wound.
- C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy
- D. Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110 mg/dL; 4-6 mmol/L] in a client with diabetes mellitus (type one)
Correct Answer: C
Rationale: Leukocytes and nitrites in urinalysis for a chemotherapy client (C) indicate a possible urinary tract infection, critical due to immunosuppression. Elevated amylase (A) and WBC (B) are expected, and glucose of 235 (D) is elevated but less urgent.
The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.