Nokea
Which of the following clients should the nurse assess first when preparing to do initial rounds?
- A. The client with diabetes who is being discharged today.
- B. A 32-year-old female with a tracheostomy experiencing copious secretions.
- C. A 16-year-old scheduled for physical therapy this morning.
- D. An 80-year-old male with a decubitus ulcer that needs a dressing change.
Correct Answer: B
Rationale: Copious tracheostomy secretions (B) pose an immediate airway obstruction risk, requiring first assessment to ensure patency. Diabetes discharge (A), physical therapy (C), and ulcer dressing (D) are less urgent, as they do not threaten immediate airway compromise.
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The nurse is caring for assigned clients. The nurse should initially follow up on the client who is
- A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C).
- B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side.
- C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous.
- D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.
Correct Answer: B
Rationale: Absent breath sounds with a chest tube for pneumothorax (B) indicate a life-threatening complication, such as tube dislodgement or re-collapse, requiring immediate assessment. A fever post-hypophysectomy (A) suggests infection but is less urgent. Nervousness from albuterol (C) is a common side effect, and cramping during dialysis (D) is less critical unless severe.
The nurse is observing practices in the behavioral health unit. Which of the practices should the nurse question?
- A. Opening all client's postal packages prior to giving them to the client.
- B. Reviewing the process of how a client may lodge a formal complaint.
- C. Allowing clients to communicate over the telephone in a private area.
- D. Allowing clients who are involuntarily admitted to refuse prescribed medication(s).
Correct Answer: D
Rationale: Allowing involuntarily admitted clients to refuse medications (D) should be questioned, as court-ordered treatment may require compliance. Opening packages (A) ensures safety, complaint processes (B) are standard, and private calls (C) respect privacy.
The nurse serves as a witness to a client giving informed consent to the primary healthcare provider (PHCP). The nurse understands that by a client giving consent this respects the client's
- A. beneficence.
- B. autonomy.
- C. nonmaleficence.
- D. confidentiality.
Correct Answer: B
Rationale: Informed consent respects client autonomy (B), allowing self-determination in medical decisions, per ethical principles. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and confidentiality (D) protects information, but autonomy is central to consent.
The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. chronic obstructive pulmonary disease (COPD) and has respiratory acidosis on the most recent arterial blood gas (ABG).
- B. atrial fibrillation taking prescribed warfarin and reports black, tarry stools.
- C. diabetes mellitus who refuses to eat following the administration of glargine insulin.
- D. acute pancreatitis and reports nausea with epigastric pain rated as a 3 on the Numerical Rating Scale.
Correct Answer: B
Rationale: Black, tarry stools in a client on warfarin (B) suggest gastrointestinal bleeding, a life-threatening complication requiring immediate assessment. Respiratory acidosis (A) is concerning but less acute if stable. Refusing to eat post-insulin (C) risks hypoglycemia but is less urgent. Pancreatitis pain (D) rated 3/10 is manageable.
The registered nurse (RN) is observing licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Positions an unconscious client semi-Fowlers for oral care
- B. Administers a bronchodilator to a client with chronic asthma
- C. Irrigates an indwelling urinary catheter with 30 ml of sterile saline
- D. Removes and reapplies weight to a client's skin traction every two hours
- E. Administers intramuscular (IM) ketorolac to a client with osteoarthritis
Correct Answer: A
Rationale: Positioning an unconscious client in semi-Fowler’s for oral care (A) risks aspiration, requiring intervention. Bronchodilator (B), catheter irrigation (C), traction adjustment (D), and ketorolac administration (E) are within LPN scope if per protocol.