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The nurse recognizes that it is acceptable for which pair of clients to be assigned to share a semi-private room?
- A. 35-year-old with blood loss anemia and a 28-year-old diagnosed with severe anorexia nervosa
- B. 50-year-old who had a bowel resection 2 days ago and a 40-year-old diagnosed with pneumonia
- C. 60-year-old who had a total hip arthroplasty yesterday and a 58-year-old with fever of unknown origin
- D. 60-year-old with gastroenteritis and a 70-year-old with diarrhea and vomiting related to chemotherapy
Correct Answer: D
Rationale: Clients with gastroenteritis and chemotherapy-induced diarrhea (D) have similar non-airborne conditions, making them suitable roommates. Pneumonia (B) and fever of unknown origin (C) pose infection risks. Anemia and anorexia (A) are unrelated but not optimal.
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The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
- A. Activate the facility's emergency response system
- B. Ask the UAP to obtain a full set of vital signs
- C. Check on the client to collect further data
- D. Immediately notify the health care provider
Correct Answer: C
Rationale: Assessing the client directly (C) confirms the report and guides next steps. Activating emergency response (A), delegating vitals (B), or notifying the provider (D) is premature without assessment.
A client receiving end-of-life care is no longer able to make decisions. The client's appointed medical power of attorney (MPOA) is considering placement of a percutaneous enterogastric feeding tube. The MPOA asks the nurse, 'What would you do if this was your family member?' How should the nurse respond?
- A. I'm not sure what I would do, but I feel confident that you will make the right decision.
- B. I will call the chaplain to help you sort through the options and discuss the issue.
- C. What do you think are the advantages and disadvantages of a feeding tube?
- D. You should meet with the family to discuss what the patient would have wanted.
Correct Answer: C
Rationale: Exploring pros and cons (C) empowers the MPOA to make an informed decision. Personal opinions (A), chaplain referral (B), or family meetings (D) are less direct.
A client admitted to the floor 3 days after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to:
- A. Apply O2 at 2 L/minute via mask.
- B. Begin chest compressions.
- C. Place the client in high Fowler's position.
- D. Administer a prescribed sedative.
Correct Answer: C
Rationale: The symptoms suggest a pulmonary embolus, a medical emergency. Placing the client in high Fowler's position facilitates breathing. Oxygen is secondary, chest compressions are inappropriate without cardiac arrest, and sedatives could worsen respiratory distress.
The nurse is assessing a young child at a clinic visit for a mild respiratory infection. Koplik spots are noted on the oral mucous membranes. The nurse should then assess which area of the body?
- A. The skin
- B. The lungs
- C. The muscles
- D. Bowel and bladder
Correct Answer: A
Rationale: The skin. A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are found on the buccal mucosa about 2 days before and after the onset of the measles rash.
A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first
- A. support the planning committee and post the new schedule
- B. explore how the planning committee evaluated barriers to the plan
- C. design a different approach to deliver care with fewer staff
- D. retain the previous staffing pattern for another 6 months
Correct Answer: B
Rationale: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated.