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While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: IT notification resolves system issues quickly.
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The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?
- A. Develop self-awareness of the nurse's personal values to avoid imposing these values on the client.
- B. Challenge members of the healthcare team whose opinions differ from the wishes of the client.
- C. Educate the client about current nursing literature findings related to the client's ethical dilemma.
- D. Listen to the ethics committee discussions and then inform the client what actions should be taken.
Correct Answer: A
Rationale: Self-awareness prevents bias in advocacy.
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
- A. Temperature.
- B. Blood pressure.
- C. Heart rate.
- D. Respiratory rate.
Correct Answer: D
Rationale: Cyanosis indicates oxygenation issues, requiring respiratory assessment.
The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
- A. Leave the dressing off until consulting with the healthcare provider.
- B. Apply a hydrocolloidal gel dressing.
- C. Replace the gauze with a transparent dressing.
- D. Increase the frequency of the dressing changes.
Correct Answer: B
Rationale: Hydrocolloidal dressing promotes healing in granulating wounds.
The nurse is assisting an older adult client who has problems with constipation and reports fear of defecation because of painful hemorrhoids, to establish a regular bowel pattern. Which action should the nurse take?
- A. Suggest using a stool softener.
- B. Recommend a daily laxative.
- C. Obtain a stool specimen.
- D. Discuss oral analgesic options.
Correct Answer: A
Rationale: Stool softeners ease defecation, reducing hemorrhoid pain.
The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
- A. Dizziness can occur during cleansing.
- B. Foreskin should not be retracted.
- C. An erection may occur while providing care.
- D. Pubic area should be kept shaved.
Correct Answer: B
Rationale: Non-retractable foreskin should not be forced to prevent discomfort.