Nokea
When a client cannot read or write but is of sound mind, the nurse should read the consent to the client in the presence of two witnesses and:
- A. Have the client's next-of-kin sign the consent.
- B. Have the client put an 'X' on the signature line.
- C. Have a court appoint a guardian for the client.
- D. Have a hospital quality management coordinator sign for the client.
Correct Answer: B
Rationale: For a client of sound mind who cannot read/write, reading the consent and having the client mark an 'X' with two witnesses ensures legal informed consent without requiring a guardian.
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A client has had hoarseness for more than 2 weeks. The nurse should:
- A. Refer to a health care provider for a prescription for an antibiotic.
- B. Instruct the client to gargle with salt water at home.
- C. Assess the client for dysphagia.
- D. Instruct the client to take a throat analgesic.
Correct Answer: C
Rationale: Persistent hoarseness may indicate laryngeal pathology, including cancer; assessing for dysphagia (difficulty swallowing) helps evaluate severity and urgency. Antibiotics are inappropriate without a bacterial diagnosis. Gargling or analgesics may mask symptoms without addressing the cause.
The client complains of aching, weakness, and a cramping sensation in both of his lower extremities while walking. The nurse knows that exercise enhances blood circulation and utilization of oxygen by the tissues. To promote health and maintain the client's level of activity, the nurse should suggest that the client try:
- A. Cross-country skiing
- B. Jogging
- C. Golfing
- D. Riding a stationary bike
Correct Answer: D
Rationale: Riding a stationary bike is a low-impact exercise that promotes circulation and oxygen utilization without excessive strain, suitable for PVD clients with claudication. Skiing and jogging may exacerbate symptoms due to high intensity, and golfing involves prolonged standing, which is less beneficial.
Which of the following positions would be appropriate for a client with severe ascites?
- A. Fowler's.
- B. Side-lying.
- C. Reverse Trendelenburg.
- D. Sims.
Correct Answer: A
Rationale: Fowler's position (A) elevates the head, reducing diaphragm pressure from ascites and improving breathing. Side-lying (B), Reverse Trendelenburg (C), and Sims (D) are less effective for respiratory relief.
The nurse in the emergency department is administering an order for 20 mg intravenous furosemide (Lasix) which is to be given immediately. The nurse seems the client's identification and the medication barcode. The medication administration system does not verify that furosemide is ordered for this client; however, the furosemide is prepared in the accurate unit dose for intravenous infusion. The nurse should do which of the following next?
- A. Contact the pharmacist immediately to check the order and the barcode label for accuracy.
- B. Administer the medication now, knowing the medication is labeled and the client is identified.
- C. Report the problem to the information technology team to have the barcode system recalibrated.
- D. Ask another nurse to verify the medication and the client so the medication can be given now.
Correct Answer: A
Rationale: A barcode verification failure indicates a potential error, requiring immediate pharmacist consultation to confirm the order and ensure patient safety.
The nurse has completed an assessment on a client with a decreased cardiac output. Which findings should receive the highest priority?
- A. BP 110/62, atrial fibrillation with HR 82, bibasilar crackles.
- B. Confusion, urine output 15 mL over the last 2 hours, orthopnea.
- C. SpO2 92 on 2 liters nasal cannula, respirations 20, 1+ edema of lower extremities.
- D. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise.
Correct Answer: B
Rationale: Confusion, low urine output, and orthopnea indicate severe heart failure with potential cerebral and renal hypoperfusion, requiring immediate intervention. Other options reflect stable or less urgent findings.