Nokea
Which client requires the most immediate intervention by the nurse?
- A. A client with acute kidney injury who is somnolent and does not respond to verbal commands.
- B. An older adult receiving enteral feedings via feeding tube who has a temperature of 100.6 F (38.1 C).
- C. A young adult who experienced heat stroke and is receiving a normal saline intravenous (IV) fluid bolus.
- D. A pregnant client with hyperemesis gravidarum who is receiving an infusion of Ringer's Lactate.
Correct Answer: A
Rationale: Somnolence in acute kidney injury suggests uremic encephalopathy, requiring immediate neurological assessment.
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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.
The charge nurse is making assignments for a 15-bed skilled nursing unit with the staff of one nurse, two practical nurses (PN), and two unlicensed assistive personnel (UAP). Which client should be assigned to the PN?
- A. The client who had bilateral above-knee amputations, now has a sacral decubitus skin flap, and is receiving vancomycin intravenously.
- B. The client who is in end-stage Alzheimer's, who requires feeding, and is waiting for a long-term facility placement.
- C. The client who has pneumonia following a total knee replacement, and is receiving clarithromycin orally.
- D. The client who has right hemiplegia as the result of a cerebral vascular accident and receives continuous gastrostomy feedings per enteral pump.
Correct Answer: C
Rationale: The pneumonia client with oral medication is stable and within the PN's scope.
The nurse-manager overhears an older female nurse complaining to a co-worker about the time being used to attend an in-service session for bioterrorism preparedness. How should the nurse-manager respond?
- A. Ask the nurse why she thinks there is no need for an in-service program about these emergencies.
- B. Encourage the nurse to share her concerns and discuss ways to prepare for such emergencies.
- C. Choose to send another nurse who is more receptive because the older nurse is not interested.
- D. Inform the older nurse that in-service is not optional and her scheduled attendance is mandatory.
Correct Answer: B
Rationale: Encouraging discussion fosters collaboration and addresses concerns constructively.
The registered nurse (RN) is gathering supplies to assist a healthcare provider with a bedside thoracentesis when the emergency department (ED) nurse calls to report on a client with unstable angina who must be admitted immediately. A practical nurse (PN) and unlicensed assistive personnel (UAP) are available to the RN. How should the RN assign the necessary nursing actions?
- A. Assign the UAP to prepare the room while the PN obtains report on the new admission and the RN assists with the thoracentesis.
- B. Assign the UAP to assist with the thoracentesis while the PN goes to the ED to transport the client to the unit and the RN obtains report from the ED nurse.
- C. Assign the PN to assist with the thoracentesis while the RN obtains report and the UAP prepares the room for the new admission.
- D. Assign the PN to go to the ED to obtain report and transport the client while the UAP prepares the room and the RN assists with the thoracentesis.
Correct Answer: D
Rationale: The PN can handle report and transport, the UAP can prepare the room, and the RN is needed for the thoracentesis.
The charge nurse needs to determine if an additional nurse should be called to help staff the unit for the next shift. Which information is most important for the charge nurse to consider when making this decision?
- A. The number of clients leaving the unit for diagnostic tests.
- B. The acuity level of the clients on the unit.
- C. The physician's plans to perform procedures on the unit.
- D. The skill level of the personnel staffing the unit.
Correct Answer: B
Rationale: Client acuity determines the intensity of care needed, critical for staffing decisions.