Nokea
The practical nurse reports that a client with a deep vein thrombosis (DVT) was mistakenly given heparin in addition to the prescribed warfarin. Which priority action should the nurse take?
- A. Notify the healthcare provider.
- B. Monitor for signs of bleeding.
- C. Complete an adverse occurrence report.
- D. Obtain blood for coagulation studies.
Correct Answer: A
Rationale: Notifying the healthcare provider ensures prompt intervention to reverse anticoagulation and prevent bleeding. Monitoring, reporting, and testing are important but follow provider notification.
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Following a six-week refresher course, a female nurse who has been out of the workforce for 10 years is assigned to a medical unit for orientation. After the first week of orientation, the charge nurse notes that the orientee is overwhelmed by her daily assignments, which are less than one-half the assignments of the regular staff, and the assignments are incomplete at the end of each day. The following week, which action is best for the charge nurse to take?
- A. Wait until the end of the second week to see if the orientee is able to complete her assignments.
- B. Assign the orientee to work with an experienced nurse who is a long-time, efficient employee.
- C. Inform the supervisor that for client safety this nurse should be assigned to a slower-paced unit.
- D. Talk to the orientee and ask her if she has considered working in a less stressful environment.
Correct Answer: B
Rationale: Pairing with an experienced nurse provides mentorship, enhancing skills and confidence. Waiting, transferring, or suggesting a less stressful environment may delay support or undermine the orientee's potential.
A charge nurse is making client assignments in the Intensive Care Department. The healthcare team consists of one nurse with 10 years experience, one nurse with 5 years experience, and a new graduate nurse who just completed a 12-week internship. Which client should the nurse assign to the new graduate nurse?
- A. A client with multisystem failure secondary to a motor vehicle collision.
- B. A client in end-stage liver failure who is experiencing esophageal bleeding.
- C. A client with Adult Respiratory Distress Syndrome who is on a ventilator.
- D. A client with chest tubes secondary to a stab wound to the chest.
Correct Answer: D
Rationale: The client with chest tubes has stable needs manageable by a new graduate with recent training. Multisystem failure, liver failure, and ARDS require advanced skills better suited to experienced nurses.
An adult woman with metastatic pancreatic cancer has requested that no heroic measures are implemented to save her life. Instructions from the healthcare provider have been received to transfer the client to a palliative care room. Which action is most important for the nurse to take first?
- A. Ensure transfer of the client's electronic chart code.
- B. Give a detailed report to the accepting nurse.
- C. Take the family to the client's new room.
- D. Give the client written information about end-of-life care.
Correct Answer: B
Rationale: Giving a detailed report ensures continuity of care, critical for the client's palliative needs. Transferring chart codes, escorting family, or providing written information are secondary to effective handoff.
An older female client who was recently widowed has become increasingly confused and disoriented. Her family tells the healthcare provider's office nurse that it is imperative for their mother to be admitted to the hospital for medical evaluation. The client is a member of a managed healthcare plan. Which information is best for the nurse to provide this family?
- A. Managed healthcare plans do not pay for any in-hospital medical evaluations.
- B. Healthcare costs are escalating because clients want to have diagnostic testing conducted in the hospital.
- C. The client is grieving normally in response to her husband's death and hospitalization is not necessary.
- D. Managed care providers have mandatory pre-certification requirements for hospitalization.
Correct Answer: D
Rationale: Informing about pre-certification requirements is factual and guides the family on necessary steps for hospitalization. Other options are inaccurate, insensitive, or dismissive of the client's medical needs.
In assigning client care to a nurse and a practical nurse (PN), it is most important to assign which client to the nurse?
- A. The client two days post-thyroidectomy and is unable to speak clearly due to laryngeal nerve damage.
- B. The client newly diagnosed with hypothyroidism and who is to receive the first dose of levothyroxine.
- C. The client with diabetes and has an elevated serum glycosylated Hgb (Hgb A1C).
- D. The client exhibiting signs of Addison's crisis after corticosteroids were discontinued.
Correct Answer: A
Rationale: Laryngeal nerve damage post-thyroidectomy risks airway obstruction, requiring RN monitoring. Hypothyroidism, diabetes, and Addison's crisis can be managed by a PN under supervision.