Nokea
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department.
Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Tell the client, 'You seem to be very upset.'
- C. Stand directly in front of the client and maintain eye contact.
- D. Speak in a firm and authoritative tone to gain control of the situation
Correct Answer: B
Rationale: The correct answer is B - Tell the client, 'You seem to be very upset.' This response shows empathy and acknowledgment of the client's emotions, which can help de-escalate the situation. It validates the client's feelings and opens the door for effective communication. Initiating seclusion protocol (A) may escalate the situation and should only be used as a last resort for safety. Standing directly in front of the client and maintaining eye contact (C) can be perceived as confrontational and may increase agitation. Speaking in a firm and authoritative tone (D) may further escalate the client's emotions. It is important to approach the situation with empathy and understanding to establish a therapeutic relationship.
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A nurse is caring for a client who is in active labor and note the FHR baseline has been 100/min for the past 15 min. The nurse should identify which of the following conditions as a possible cause of fetal bradycardia?
- A. Maternal fever
- B. Fetal anemia
- C. Maternal hypoglycemia
- D. Chorioamnionitis
Correct Answer: B
Rationale: The correct answer is B: Fetal anemia. Fetal bradycardia (baseline <110/min) can be caused by inadequate oxygen delivery to the fetus, such as in fetal anemia. Anemia decreases the blood's ability to carry oxygen, leading to fetal distress. Maternal fever (A) can increase the fetal heart rate, not decrease it. Maternal hypoglycemia (C) can cause fetal distress, but typically presents with fetal tachycardia. Chorioamnionitis (D) can cause maternal fever and tachycardia, but is less likely to directly affect the fetal heart rate. Other choices are not provided.
A nurse is planning to delegate to an AP the fasting blood glucose testing for a client who has diabetes mellitus.
Which of the following action should the nurse take?
- A. Determine if the AP has the skills to perform the test.
- B. Help the AP performed the blood glucose test
- C. Assign the AP to ask the client is taking his diabetic medication today
- D. Have AP check the medical record for prior blood glucose test results
Correct Answer: A
Rationale: The correct answer is A because the nurse should first assess if the AP has the necessary skills to perform the blood glucose test. This step is crucial to ensure patient safety and accurate test results. Helping the AP perform the test (B) without assessing their skills can lead to errors. Assigning the AP to ask about medication (C) is not directly related to the task at hand. Having the AP check records (D) is important but should come after confirming their skills. The other choices are not relevant to the immediate situation.
A nurse enters a client's room and sees a small fire in the client's bathroom.
Identify the sequence of steps the nurse should take?
- A. Close all nearby windows and doors
- B. Transport the client to another area of the nursing unit
- C. Use the unit's fire extinguisher to attempt to put out the fire
- D. Activate the facility's fire alarm system
Correct Answer: D
Rationale: The correct answer is D: Activate the facility's fire alarm system. This is the first step the nurse should take in case of a fire emergency to ensure the safety of all individuals in the facility. Activating the fire alarm alerts everyone in the building about the fire and prompts an immediate response from the fire department. Closing windows and doors (A) may help contain the fire but should not be the initial action. Transporting the client (B) could put them at risk and is not a priority. Using the fire extinguisher (C) should only be done if safe and appropriate, but activating the alarm is more crucial.
A nurse is planning care for a client who is to receive alteplase recombinant for a thrombus in the coronary artery.
Which of the following actions should the nurse include in the plan of care?
- A. Observe for bruising of the skin
- B. Provide a diet low in protein
- C. Monitor v/s every hour for the first 4 hr.
- D. Administer medications intramuscularly
Correct Answer: A
Rationale: The correct answer is A: Observe for bruising of the skin. This is important in assessing for potential complications such as bleeding disorders, which may indicate a need for further intervention. Providing a diet low in protein (B) is not relevant to the scenario unless specified. Monitoring vital signs every hour for the first 4 hours (C) may not be necessary unless there are specific concerns. Administering medications intramuscularly (D) is not indicated without further context.
A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube.
Which of the following actions is appropriate for the nurse to take?
- A. Add medication directly to enteral feeding
- B. Dissolve the medication together
- C. Use a syringe to allow the medications to flow by gravity
- D. Flush the NG tube with 5 ml water
Correct Answer: D
Rationale: The correct answer is D: Flush the NG tube with 5 ml water. This action is appropriate because flushing the NG tube with water helps prevent clogging and ensures proper medication administration. Adding medication directly to enteral feeding (choice A) can lead to tube clogging. Dissolving medications together (choice B) can alter their effectiveness. Using a syringe to allow medications to flow by gravity (choice C) may not be sufficient for complete administration. Flushing the NG tube with water (choice D) maintains tube patency. No further choices provided.