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The RN is making assignments on a 12-bed unit. Staff consists of one RN and two certified nursing assistants. Which client should be self-assigned?
- A. A client receiving decadron for emphysema
- B. A client with chest trauma and a new onset of hemoptysis
- C. A client with rib fractures and an O2 saturation of 93%
- D. A client 2 days post-operative lung surgery with a pulse oximetry of 92%
Correct Answer: B
Rationale: New-onset hemoptysis in a chest trauma client indicates potential serious complications (e.g., pulmonary hemorrhage) requiring RN assessment and intervention.
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A nurse needs to draw a blood sample from a patient's central line. The line is currently infusing Ringer's lactate. In which order should the nurse take the following steps to draw the blood sample? Number the steps below.
- A. attach the flush syringe and flush catheter with normal saline
- B. stop the infusion and disconnect Ringer's lactate
- C. withdraw a blood sample and discard
- D. scrub the catheter hub
- E. withdraw the blood sample for the lab
Correct Answer: B,D,C,A,E
Rationale: Order: Stop infusion (B), scrub hub (D), withdraw/discard blood (C), flush with saline (A), withdraw lab sample (E). This ensures a clean, accurate sample.
A client is to be discharged on warfarin (Coumadin®) therapy, and the nurse is teaching the client about the medication. Which of the following statements by the client indicates that the client's education has been effective? Select all that apply.
- A. I should use a soft toothbrush.
- B. My stools will routinely be black.
- C. Swimming is a good choice for exercise.
- D. I should wear a Medical Alert bracelet.
- E. I should avoid all green, leafy vegetables.
Correct Answer: A,C,D
Rationale: Soft toothbrush (A), swimming (C), and Medical Alert bracelet (D) reduce bleeding risk and ensure safety. Black stools (B) indicate bleeding, and avoiding all leafy greens (E) is excessive.
A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
- A. Placing mirrors in several locations in the home
- B. Placing a picture of herself in her bedroom
- C. Placing simple signs to indicate the location of the bedroom, bathroom, and so on
- D. Alternating healthcare workers to prevent boredom
Correct Answer: C
Rationale: Simple signs help orient clients with Alzheimer's, reducing confusion and promoting independence in a new environment.
A client's lab results have just come in. The nurse reviews the electrolytes and contacts the health care provider regarding which result?
- A. chloride 167 mEq/L
- B. calcium 9.3 mg/dL
- C. phosphate 3.8 mg/dL
- D. sodium 141 mEq/L
Correct Answer: A
Rationale: Chloride 167 mEq/L is severely elevated (normal 98-106 mEq/L), requiring immediate attention. Other values are normal.
A burn client begins treatments with silver sulfadiazine (Silvadene) applied to the wounds. The nurse should carefully monitor for which adverse affect associated with this drug?
- A. Hypokalemia
- B. Leukopenia
- C. Hyponatremia
- D. Thrombocytopenia
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia as an adverse effect, requiring monitoring of white blood cell counts to detect potential bone marrow suppression.