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The nurse working on a medical-surgical unit has just received a change-of-shift report. The nurse should initially assess the client who is
- A. receiving treatment for chronic pulmonary emphysema with PaCO2 of 50 mm Hg.
- B. admitted with pulmonary tuberculosis (TB) and refuses their prescribed isoniazid.
- C. infected with Clostridium difficile, and is reporting dizziness.
- D. being treated for acute pyelonephritis and has a temperature of 101.8°F (38.7°C).
Correct Answer: C
Rationale: Dizziness with Clostridium difficile infection (C) suggests dehydration or electrolyte imbalance, which can lead to falls or cardiovascular instability, requiring immediate assessment. A PaCO2 of 50 mm Hg in chronic emphysema (A) is often a baseline finding, TB medication refusal (B) is concerning but not immediately life-threatening, and fever in pyelonephritis (D) is expected and less urgent than acute instability.
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The nurse approached a client with a blood pressure cuff, and the client extended their arm to allow the nurse to obtain a reading. The nurse understands that this exemplifies what type of consent?
- A. Informed consent
- B. Implied consent
- C. Expressive consent
- D. Written consent
Correct Answer: B
Rationale: Extending an arm for a blood pressure reading (B) is implied consent, as the client’s action indicates agreement. Informed consent (A) requires explanation, expressive consent (C) is not a standard term, and written consent (D) is for procedures.
A nurse is performing disaster triage at a field hospital following a structural collapse. Advanced life support resources are limited. Which client should be assigned a black tag?
- A. A client with a penetrating head wound, unresponsive to pain, irregular respirations, and a fixed, dilated pupil
- B. A client with a chest wall bruise, shallow respirations, and tracheal deviation to the right
- C. A client with an open femur fracture, cool extremity, delayed capillary refill, and confusion
- D. A client who is found conscious, but unable to move the legs, with a distended abdomen and bruising across the lower torso
Correct Answer: A
Rationale: A black tag (A) is assigned to clients unlikely to survive, such as one with a penetrating head wound, unresponsive, irregular respirations, and fixed pupil, indicating severe brain injury. Chest trauma (B), femur fracture (C), and spinal/abdominal injury (D) have higher survival potential.
The nurse is conducting a staff in-service on client privacy. Which of the following actions would the nurse recognize as violations of client confidentiality? Select all that apply.
- A. Accessing a co-worker's address in their medical record to surprise them with a birthday gift.
- B. Reviewing a client's prescriptions with a student nurse who is assigned to the client.
- C. Looking up the medical information of a friend from a previous stay, even with their permission.
- D. Viewing a friend's medical record because you are listed as their power of attorney.
- E. Walking away from a computer terminal without securing it, even if the monitor is turned off.
Correct Answer: A, C, E
Rationale: Accessing a co-worker’s record for personal reasons (A), viewing a friend’s past record without current need (C), and leaving an unsecured computer (E) violate HIPAA confidentiality rules. Reviewing prescriptions with an assigned student (B) is educational, and viewing as power of attorney (D) may be authorized.
A nurse is caring for four clients on a medical-surgical unit. Which client should the nurse assess first?
- A. A client with a blood glucose of 250 mg/dL [70–100 mg/dL, 4.0–5.6 mmol/L] who is requesting insulin coverage.
- B. A client post-thyroidectomy with a hoarse voice and difficulty speaking.
- C. A client with pneumonia reporting shortness of breath after ambulating.
- D. A client post-cholecystectomy requesting pain medication for a pain score of 7/10 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Hoarse voice and difficulty speaking post-thyroidectomy (B) suggest possible laryngeal nerve damage or hypocalcemia, life-threatening complications requiring immediate assessment. High glucose (A), shortness of breath (C), and pain (D) are less acute.
The nurse has been made aware that the following clients require assistance. The nurse should first assist the client
- A. experiencing a flare-up of ulcerative colitis and has had 2 bloody bowel movements in the past hour.
- B. with a cerebral aneurysm, has developed nausea and vomiting.
- C. taking prescribed prednisone for an allergic reaction and reports indigestion.
- D. being treated for Bell's palsy and reports ringing in their ears.
Correct Answer: A
Rationale: Bloody bowel movements in ulcerative colitis (A) suggest active bleeding, requiring immediate assistance to prevent hypovolemia. Nausea with aneurysm (B), indigestion with prednisone (C), and tinnitus with Bell’s palsy (D) are less urgent.