Nokea
Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: C
Rationale: The correct answer is C: A client who is ambulatory and receiving oxygen. This client should be evacuated first because they are at risk for oxygen-related complications during an emergency. Oxygen supports combustion, increasing the risk of fire. The priority is to remove this client from the area to prevent harm. The other choices are incorrect because: A: Although the client is confused and uses a wheelchair, they are not at immediate risk of harm related to their condition. B: The client who is bedridden and wears a hearing aid is also not at immediate risk of harm. D: The client with a fracture in balance suspension traction can be safely evacuated with assistance and does not have an immediate life-threatening condition.
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Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.
Which of the following manifestations should the nurse expect?
- A. Crackles in the lungs
- B. Bradycardia
- C. Dry mucous membranes
- D. Weight loss
Correct Answer: A
Rationale: The correct answer is A: Crackles in the lungs. This manifestation is expected in conditions like heart failure or pneumonia due to fluid accumulation in the lungs. Crackles are abnormal lung sounds heard on auscultation. Bradycardia (B) is a slow heart rate, not typically associated with these conditions. Dry mucous membranes (C) can indicate dehydration but are not specific to lung issues. Weight loss (D) may occur in chronic conditions but is not a direct manifestation of fluid in the lungs. Therefore, crackles in the lungs are the most likely manifestation to expect in this scenario.
In anticipation of multiple client admissions, which of the following current clients should the nurse recommend for early discharge?
- A. A client who was one day postoperative following a vertebroplasty.
- B. A client receiving IV antibiotics for pneumonia with a fever of 101°F(38.3°C).
- C. A client who had a transient ischemic attack(TIA) 12 hours ago and is awaiting further evaluation.
- D. A client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring.
Correct Answer: A
Rationale: The correct answer is A. The client one day postoperative following a vertebroplasty can be recommended for early discharge as this procedure is typically short-stay and does not require extended monitoring. The client is likely stable and can continue recovery at home.
Choice B is incorrect because a client with pneumonia and a fever of 101°F requires continued IV antibiotics and monitoring to ensure resolution of infection and fever reduction.
Choice C is incorrect as a client with a recent TIA requires further evaluation and monitoring to prevent recurrent strokes and assess for potential complications.
Choice D is incorrect because a client with uncontrolled atrial fibrillation requiring continuous cardiac monitoring should not be discharged early as they need close monitoring and management to prevent complications like stroke or heart failure.
Which action should the nurse take to protect the client's confidentiality?
- A. Provide a verbal report of the client's condition to the paramedic performing the transfer
- B. Ensure that the client's medical records are securely transferred with the client to the new facility
- C. Give the client a copy of their medical records to take with them
- D. Share the client's condition only with the necessary healthcare providers at the rehabilitation facility
- E. Use a secure and private communication method to discuss the client's condition with the receiving facility
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice B) is important, discussing the client's condition directly with the necessary healthcare providers (choice D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice C) can compromise confidentiality if misplaced.
Which of the following actions should the nurse take?
- A. Compare the current infusion with the prescription and the client's medical record.
- B. Adjust the IV infusion rate to match the information received during the shift report.
- C. Stop the infusion immediately and notify the provider.
- D. Document the discrepancy in the client's record and continue monitoring the infusion.
Correct Answer: A
Rationale: The correct answer is A. The nurse should compare the current infusion with the prescription and the client's medical record to ensure accuracy and safety. This step is crucial in preventing medication errors and ensuring that the right medication is given to the right patient at the right time. Adjusting the IV infusion rate without verifying the information can lead to potential harm (choice B). Stopping the infusion immediately and notifying the provider is not necessary unless there is a clear indication of a serious issue (choice C). Documenting the discrepancy and continuing monitoring without taking immediate action can compromise patient safety (choice D).