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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.
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A client with life-threatening injuries from a gunshot wound to the abdomen is mechanically ventilated and sedated. The client has a large family present who are asking multiple and repetitive questions. Which intervention should the nurse implement first?
- A. Let each family member ask a question one at a time.
- B. Request the healthcare provider to speak with the family.
- C. Page a chaplain on call to be present for questions.
- D. Ask the family to identify a specific spokesperson.
Correct Answer: D
Rationale: Identifying a spokesperson streamlines communication, reducing confusion and repetitive questions.
A male college student is brought to an emergency clinic by his friends because they report that he has been vomiting for the past two days as a result of food poisoning. Laboratory findings indicate that the client's potassium level is 2.5 mEq/L (2.5 mmol/L), so he is admitted to a local hospital. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor client's electrocardiogram continuously.
- B. Inject prescribed potassium chloride IV push slowly.
- C. Assess level of consciousness every 4 hours.
- D. Instruct client on dietary intake of potassium-rich foods.
Correct Answer: A
Rationale: Continuous ECG monitoring is critical due to hypokalemia's risk of causing life-threatening arrhythmias.
After implementation of new policies related to client identification prior to medication administration, the frequency of medication errors remains unchanged. Which should be the nurse manager's next action?
- A. Provide revised procedural updates through additional nursing staff education programs.
- B. Examine medication administration data to determine use of new policy by nursing staff.
- C. Investigate identified procedural variances in medication administration with nursing staff.
- D. Determine changes in procedure needed to reduce the frequency of medication errors.
Correct Answer: B
Rationale: Examining data assesses policy compliance, identifying gaps to address persistent errors.
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.
An older client who had a hernia repair 12 hours ago suddenly becomes agitated, pulls out the intravenous (IV) catheter, and staggers out into the corridor, demanding to be set free. The nurse assists the client back to bed and re-establishes the IV access. Which intervention is most important for the nurse to implement prior to leaving the client's room?
- A. Discuss with the family about placing the client in a skilled care facility.
- B. Determine if the client is manifesting other neurologic changes.
- C. Apply a restraining device to prevent the client from self injury.
- D. Request family members report when the client is left alone.
Correct Answer: B
Rationale: Assessing for neurologic changes identifies potential causes of agitation, such as delirium or hypoxia.