The nurse is caring for an elderly client with osteoporosis who has fractured her mid-shaft clavicle. Which nursing intervention would be included on the plan of care?
Rationale:
Immobilize the affected shoulder with a sling. This intervention is critical for managing a fractured mid-shaft clavicle, as it promotes healing by preventing further movement and reducing pain, which is essential for elderly clients with osteoporosis.
B: Encourage weight-bearing exercise. Weight-bearing activities are not advisable immediately after a fracture, as they may lead to further injury or complications in an elderly client with fragile bones.
C: Increase fluids to 1,500 cc/day. While hydration is important, this intervention does not directly address the immediate needs of managing a shoulder fracture and is not specific to fracture care.
D: Prepare for surgical repair. Surgical intervention is not typically required for a mid-shaft clavicle fracture in an elderly client, especially when conservative management can effectively promote healing.
The nurse is caring for a client who is a Jehovah's Witness and is scheduled for hip replacement surgery. The client refuses to sign consent for blood due to religious reasons. The client's daughter has the power of attorney in case the client is unable to state his wishes regarding health care. The daughter tells the nurse, 'I'm afraid if something goes wrong, dad might need blood. I want to sign a blood consent form since I'm his power of attorney.' The daughter is not a Jehovah's Witness. Which action by the nurse is the best in this situation?
Rationale:
The client clearly does not wish to receive blood due to his religious beliefs, and the nurse must uphold the client's autonomy and previously expressed wishes, regardless of the daughter's concerns.
A: notify the charge nurse so that she can ask the night shift nurse to handle the situation. This action delays addressing the client’s clear wishes and does not prioritize the ethical obligation to respect his religious beliefs.
B: go and get a blood consent form for the daughter to sign, noting that she has power of attorney over the client. This disregards the client's explicit refusal of blood, undermining his autonomy and spiritual convictions.
C: notify the surgeon that the client's daughter has power of attorney and will be signing a blood consent form so that an order may be obtained for a type and cross. This action fails to honor the client's established wishes regarding blood transfusions and violates ethical standards of patient consent and autonomy.
A nurse is caring for a client in the immediate post-cardiac catheterization period. Which intervention should the nurse include in the client's care?
Rationale:
A: monitor vital signs every 30 minutes for the first 2 hours. Frequent monitoring of vital signs is crucial in the immediate post-cardiac catheterization period to detect early signs of complications or distress, ensuring prompt intervention if needed.
C: maintain the client in a prone position. A prone position is not suitable post-cardiac catheterization; it can compromise access to the insertion site and impede proper monitoring and care.
D: keep the client NPO for 2 hours. Clients typically do not need to remain NPO after cardiac catheterization unless specified for certain tests or procedures, as hydration and nutrition can be resumed earlier.
The school nurse is monitoring the diet of a child with celiac disease. What lunch menu item would the nurse recommend to the family?
Rationale:
A: ham and cheese sandwich This option contains gluten from the bread, making it unsuitable for a child with celiac disease who must avoid gluten-containing foods to prevent adverse health effects.
C: chili with corn bread Cornbread typically contains wheat flour, which is not safe for a child with celiac disease, as it can trigger harmful reactions in their digestive system.
D: vegetarian pizza with lactose-free cheese Pizza crust often contains gluten, posing a significant risk for someone with celiac disease, who must strictly adhere to a gluten-free diet for health reasons.
A local volunteer singing group performs in the activity room of a long-term care facility. The group's leader asks the nurse if they may take a photo of themselves with several of the clients. The nurse gives permission to the leader, who then posts the photo on Facebook. Upon notification of this situation, the facility administration immediately terminates the nurse. What Health Insurance Portability and Accountability Act (HIPAA) violation did the nurse commit?
Rationale:
A breach of confidentiality occurred when the nurse allowed a photo of clients to be taken and posted online without ensuring their privacy rights were protected, violating HIPAA regulations.
B: failure to seek administrative approval The nurse's actions involved client privacy rather than administrative procedures, making this option irrelevant to the specific violation committed in this scenario.
C: unethical conduct This term is too broad; the nurse's actions specifically relate to confidentiality and privacy rights under HIPAA, rather than general ethical standards in healthcare.
D: unprofessional conduct While the nurse's actions were unprofessional, this term does not specifically address the violation of patient confidentiality mandated by HIPAA regulations concerning private health information.
The school nurse is assessing the readiness of a 16-year-old athlete who is diabetic. As the teenager becomes more physically active during the day, which management strategies should the nurse advise? Select all that apply.
Rationale:
Monitor blood glucose level before exercise and let the coach know the athlete is a diabetic.
Monitoring glucose ensures safety during physical activity, while informing the coach facilitates necessary support and adjustments. Both strategies are vital for managing diabetes effectively during increased physical exertion.
B: Always carry some form of high-protein, high-fat snack. This option may not provide immediate glucose support; quick-acting carbohydrates are usually more effective for managing blood sugar during exercise.
D: Inject insulin at least 30 minutes prior to athletic event. Timing of insulin administration can vary based on individual needs; administering too early might lead to hypoglycemia during the activity.
The RN is precepting a nursing student in the surgical ICU. The client is diabetic and asks the student nurse about insulin. Which response by the RN is best?
Rationale:
D: Allowing the nursing student to answer the client's question while the RN is present promotes a learning opportunity. This approach fosters communication and ensures the client receives accurate information with professional guidance available.
A: Ask the family to step out of the room to ensure client privacy. This action may unnecessarily isolate the client and family, potentially increasing anxiety during an important discussion about health.
B: Tell the client that he should ask the health care provider when she rounds. This deferral disregards the student nurse's role and limits immediate patient education, which can enhance understanding of their care.
C: Inform the client that the student nurse cannot answer questions regarding medication. This response undermines the student's learning experience and misses an opportunity to provide relevant information in collaboration with the RN.
The ED nurse is working in triage on a summer weekend. The following clients present at the same time. Which client does the nurse anticipate being seen first?
Rationale:
An infant with fever, a shrill cry, diarrhea, and nuchal rigidity is anticipated to be seen first. This scenario suggests possible meningitis or severe infection, both critical conditions requiring immediate medical attention to prevent complications or deterioration.
A: a 58-year-old man with abdominal pain and nausea. While concerning, abdominal pain may not indicate an immediate life-threatening condition compared to the infant's symptoms.
C: a 38-year-old jogger who twisted her ankle, has a good pedal pulse, and has no deformity. This situation presents a minor injury that does not require urgent intervention relative to the other cases.
D: a 46-year-old client who was working outside and has tachypnea, diaphoresis, and fatigue. Although these symptoms are serious, they do not signify an immediate life-threatening emergency like the infant's condition.
E: an ambulatory child who fell off a bicycle and hit his head on grass while wearing a helmet. The helmet may have mitigated injury severity, making this case less urgent than the infant's potentially severe symptoms.
The nurse is caring for a client admitted for right-sided renal artery stenosis. Where should the nurse anticipate auscultating for a renal bruit?
Rationale:
A: right renal artery. A renal bruit is typically auscultated over the affected artery, indicating turbulent blood flow. In cases of right-sided renal artery stenosis, the nurse should specifically listen over the right renal artery for any abnormal sounds indicative of this condition.
B: right iliac artery. The right iliac artery is not directly associated with the renal system and would not produce a bruit related to renal artery stenosis.
C: left renal artery. Auscultating the left renal artery does not provide relevant information about right-sided renal artery stenosis and would not reveal the bruit signifying turbulence in the affected artery.
D: left iliac artery. The left iliac artery is unrelated to the right renal artery and would not exhibit any sounds indicative of stenosis affecting the right renal artery.
Which statement concerning informed consent is false?
Rationale:
Persons 17 years of age and younger may not give informed consent.
Informed consent typically requires individuals to be of legal age, which is usually 18 years. While minors generally cannot provide consent, certain circumstances like marriage can grant them this ability, making option B an inaccurate statement.
A: Persons 17 years of age and younger may not give informed consent. This statement is accurate, as minors under 18 typically lack the legal capacity to provide informed consent.
C: A pregnant minor may give informed consent. This statement holds true, as pregnant minors are often considered capable of making their own medical decisions, including providing informed consent.
D: An adult 18 years of age and older may give informed consent. This statement is factual, as individuals who are 18 or older are legally recognized as adults and can provide informed consent.
A newly graduated nurse has been assigned a client who has a chest tube following a thoracotomy. The new nurse is not experienced with chest tube management. Which action by the nurse is most appropriate regarding this assignment?
Rationale:
D: Accept the assignment and ask for another nurse to help her with the chest tube. This action demonstrates a willingness to learn while ensuring the patient receives safe, competent care through collaboration.
A: Ask for a different group of clients. This choice avoids responsibility and does not promote skill development or teamwork, ultimately compromising patient care and the nurse's professional growth.
B: Ask to be floated to another area in the facility. This option neglects the immediate need for assistance and does not address the responsibility to support patient care within the assigned unit.
C: Refuse the assignment, since she is not familiar with chest tubes. This stance denies the opportunity for learning and collaboration, which are essential in nursing practice, particularly in unfamiliar situations.
The RN is assigning a client to the LPN. The RN understands that the best assignment for the LPN is which client?
Rationale:
C: a client who will receive enemas in preparation for a colonoscopy. This assignment is appropriate for the LPN, as administering enemas falls within their scope of practice and does not require the RN's advanced skills or assessment capabilities.
A: a client receiving blood for a GI bleed. This situation demands close monitoring and assessment, which is primarily within the RN's responsibilities due to the potential for serious complications.
B: a client with a PICC line requiring TPN. Managing a central line and administering TPN necessitates a higher level of nursing judgment and assessment skills, which are typically performed by RNs.
D: a client who needs preoperative teaching for bowel resection surgery. Preoperative education requires comprehensive knowledge and critical thinking to address potential complications and patient concerns, best handled by an RN.
The nurse is caring for an elderly client who is 1 day post-hip replacement surgery. Which nursing interventions should be included on the care plan? Select all that apply.
Rationale:
Apply compression stockings, ambulate with a walker, and encourage coughing and deep breathing every 2 hours are essential interventions to promote circulation, mobility, and respiratory function in post-operative clients.
A: apply compression stockings Effective for preventing deep vein thrombosis, compression stockings enhance venous return and reduce swelling, crucial in post-surgery recovery for elderly clients.
B: ambulate with walker Assisting mobility with a walker is vital for safety and rehabilitation, enabling the elderly client to maintain independence and prevent complications such as falls.
C: encourage coughing and deep breathing every 2 hours Promoting respiratory exercises alleviates the risk of pneumonia and enhances lung expansion, critical for recovery following anesthesia and surgery.
D: limit fluid intake Reducing fluid intake can lead to dehydration and hinder the healing process, counteracting the necessity for adequate hydration post-surgery.
The charge nurse is teaching unit nurses about droplet precautions. Which statement by one of the nurses indicates further teaching is needed by the charge nurse?
Rationale:
Pharyngeal diphtheria is a bacterial infection, not viral, which does not require droplet precautions. This misunderstanding indicates that the nurse lacks accurate knowledge about the specific infection control measures needed.
A: Mumps is a viral infection that requires droplet precautions. This statement is accurate, as mumps is indeed a viral condition requiring such measures to prevent transmission.
C: Pertussis is a bacterial respiratory infection that requires droplet precautions. This statement is true, as pertussis, also known as whooping cough, necessitates droplet precautions for effective infection control.
D: Mycoplasma pneumonia is a bacterial respiratory infection that requires droplet precautions. This claim is misleading since mycoplasma pneumonia typically requires airborne or contact precautions, not droplet precautions.
The nurse is working triage in the ED when four clients present at the same time. Which client should be seen first?
Rationale:
C: an irritable 4-month-old with a petechial rash, nuchal rigidity, and temperature of 103.4°F. This client exhibits signs of potentially serious conditions like meningitis, requiring immediate assessment and intervention to prevent severe complications or deterioration of health.
A: a 45-year-old female on oral contraceptives with unusually heavy menstrual bleeding. While concerning, her condition is not immediately life-threatening compared to the infant's critical signs indicating possible systemic infection.
B: a 24-year-old with a dog bite to the leg from the family dog who is current on rabies shots. This situation is important but less urgent, as rabies vaccination reduces the risk of severe consequences from the bite.
D: a 16-year-old football player with a twisted ankle who has no deformity and a pedal pulse. This injury, although painful, is a non-life-threatening issue and can safely wait for evaluation after more critical cases.
A nurse is talking to a nursing student about quality improvement and nurse-sensitive indicators. The nurse knows that the nursing student understands quality improvement when she identifies which to be nurse-sensitive indicators? Select all that apply.
Rationale:
Nurse-sensitive indicators include fall injury rates, restraint utilization rates, pressure ulcer prevalence and incidence, and client satisfaction with pain management. These metrics directly reflect the quality of nursing care delivered to patients.
C: staying within the unit budget. This pertains more to financial management than to direct patient care outcomes influenced by nursing practices.
D: upgrading computer charting programs. While important for efficiency, this does not directly measure nursing care effectiveness or patient outcomes, thus lacking sensitivity to nursing practices.
The charge nurse in the medical unit is preparing a bed assignment for a stable client diagnosed with necrotizing fasciitis. The client has a history of diabetes and hepatitis. There are four beds available. The nurse knows that the best roommate for this client is which of the following?
Rationale:
A client with gout in the large toe is the best roommate for the client diagnosed with necrotizing fasciitis.
This option is appropriate as gout is a localized condition, posing minimal risk of infection transmission and complications for the diabetic patient, while allowing for stable management of both conditions without exacerbating the client's health issues.
B: a client with fever, vomiting, and diarrhea This option represents a contagious illness, increasing the risk of infection for the stable client, especially considering their compromised health status.
C: a client with MRSA This choice poses a significant risk of cross-contamination and infection, as MRSA is a highly resistant strain of bacteria that could severely impact the diabetic client’s recovery.
D: a client with severe dementia with a tendency to wander This option may lead to safety concerns and potential distress for the client with necrotizing fasciitis, compromising the overall care environment and stability.
The role of the nurse as patient advocate is accurately identified in which of these statements?
Rationale:
Nurses work with patients, their families, other health care team members and third-party persons. This comprehensive approach highlights the multifaceted role of nurses in advocating for patients' needs and rights across various contexts.
A: Nurses evaluate only the negative outcomes of patient advocacy. This perspective neglects the positive impacts of advocacy, such as promoting patient rights and improving care quality.
B: Nurses provide only physical and emotional support. Advocacy extends beyond support, involving active engagement in decision-making processes and ensuring patient voices are heard in health care.
C: Advocacy practices are limited to within health care settings. Advocacy transcends institutional boundaries, encompassing community resources and external support systems, making it a broader responsibility.
A toddler in gastric distress is admitted to the pediatric intensive care unit. The toddler becomes anxious and tries to remove the IV. The mother offers to help calm the child. Which action by the nurse is most appropriate?
Rationale:
Asking the mother to read the child's favorite book is the most appropriate action. This approach utilizes familiar comfort and emotional support, helping to distract and reassure the anxious toddler during a stressful situation.
A: Paint a smiley face on the dressing covering the IV site. While this may seem playful, it does not address the child's anxiety or provide meaningful distraction.
B: Give the child a puzzle to complete. Engaging in a puzzle requires cognitive effort that may not effectively soothe the child's immediate distress or anxiety.
D: Administer a sedative to the child. Sedating the toddler could lead to unnecessary side effects and does not address the root cause of the child's anxiety or provide comfort.
A client undergoes total shoulder replacement on the left shoulder. Which statements by the client indicates he requires further teaching? Select all that apply.
Rationale:
I look forward to soaking in my hot tub when I get home from surgery. This statement indicates a misunderstanding, as soaking in hot water can increase swelling and risk complications post-surgery.
A: I look forward to soaking in my hot tub when I get home from surgery. Immersion in hot water can lead to increased swelling and other complications during recovery.
B: The surgery will eliminate my pain within 24 hours. Pain relief varies significantly among patients, and complete elimination of pain is unrealistic shortly after surgery.
C: I will receive therapy for several weeks after my surgery. This statement reflects understanding, as physical therapy is essential for regaining mobility and strength post-surgery.
D: Walking is an exercise I'll be able to do after surgery. While walking is typically encouraged, it's vital to follow specific post-operative guidelines for safe implementation.
A nurse on a busy surgical floor is working with an unlicensed assistive personnel (UAP). The nurse understands that which task cannot be delegated to the UAP?
Rationale:
C: Calling report on a client who is being transferred to the observation floor requires a licensed nurse’s clinical judgment and accountability, making it a task that cannot be delegated to a UAP.
A: Assisting a stable client to set up her meal tray for easy access involves routine tasks that do not require nursing judgment, making it suitable for a UAP.
B: Assisting a client with an arm cast onto the bedpan entails basic support tasks that UAPs are equipped to handle without needing specialized nursing skills.
D: Helping a client ambulate in the hall who is post-op day 2 from a cardiac catheterization involves monitoring vital signs and safety, which are nursing responsibilities not suitable for UAPs.
The nurse is working with a newly hired unlicensed assistive personnel (UAP). Several activities of daily living need to be completed for the nurse's clients. Which task should the nurse delegate to the UAP?
Rationale:
C: assisting a client admitted with COPD exacerbation to the chair. This task is appropriate for UAP as it involves basic assistance with mobility, allowing the nurse to focus on more complex care needs.
A: performing oral care on a client with a bleeding disorder. This task requires careful assessment and knowledge of bleeding risks, which UAP may not possess adequately.
B: turning a client with a tibial fracture with external fixation. This involves special techniques to avoid dislodging the fixation device, necessitating the nurse's expertise for safe execution.
D: reinforcing teaching on use of the inhaler for a client with asthma. Teaching requires a comprehensive understanding of the medication and technique, which UAP typically cannot provide.
The nurse is caring for a client on the orthopedic unit who had a total knee replacement on the left side. The nurse knows the client will be ready for discharge when she is able to do which of the following activities?
Rationale:
Ambulating 100 feet with crutches or a walker indicates that the client has achieved sufficient mobility and stability, essential for safe discharge after a total knee replacement. This activity demonstrates effective weight-bearing and strength, crucial for recovery.
B: get up and down a flight of stairs. Mastering stairs requires more strength and balance than ambulating 100 feet, which is a prerequisite for ensuring safe discharge.
C: flex the surgical knee 30 degrees. Achieving only 30 degrees of flexion is inadequate for functional mobility post-surgery, as greater range of motion is typically necessary for discharge readiness.
D: fix a snack. This task does not reflect the mobility, stability, and weight-bearing capacities needed for safe discharge following a total knee replacement procedure.
The nurse is caring for a client with an infected leg wound. The client develops a fever of 102°F. Which action by the nurse is the priority for this client?
Rationale:
Administer IV antibiotic as scheduled. This action is crucial as it directly targets the infection causing the fever, promoting healing and preventing further complications. Timely antibiotic administration is essential in managing the client's condition effectively.
A: Obtain a wound culture. While this helps identify the infection's causative agent, it does not provide immediate treatment or address the fever's underlying cause.
B: Administer acetaminophen. Reducing fever may provide comfort, but it does not address the infection directly or improve the client's overall condition as promptly as antibiotics would.
D: Perform the scheduled dressing change. Although necessary for wound care, changing the dressing does not address the systemic infection or fever, making it less urgent than administering antibiotics.
A client has been admitted to the oncology unit and has a large amount of cash, several credit cards, and several pieces of expensive-looking gold jewelry in her possession. Which action by the nurse is most appropriate?
Rationale:
Informing the client of the hospital policy regarding valuables and suggesting she give them to a trusted family member or to security for safekeeping ensures her belongings are protected and appropriately managed. This action aligns with institutional protocols aimed at safeguarding personal items.
A: tell the client to hide everything in her purse or a bag and put it in the closet. This suggestion does not ensure security and may lead to theft or loss of valuable items.
B: offer to take her belongings to the charge nurse's office where they can be locked up. This option lacks direct communication with the client about her choices, which is essential for her understanding and trust.
C: suggest that the client put her valuables in a sock and place it in the bottom of the bedside table under some clothing. This method is insecure and does not follow recommended hospital procedures for safeguarding valuables.
The nurse is caring for clients on a medical-surgical floor. Which tasks related to pain management can be delegated to unlicensed assistive personnel (UAP)? Select all that apply.
Rationale:
Reminding clients to report pain immediately, reporting facial grimacing in unresponsive clients, and asking clients directly if they are experiencing pain are tasks that UAPs can perform under supervision. These actions support the nurse's role in pain management while ensuring timely communication of patient needs.
A: assessing the pain level on a scale of 1-10 This task requires clinical judgment and understanding of pain assessment, which UAPs are not trained to perform accurately.
E: giving acetaminophen (Tylenol) after the nurse obtains the medication but is interrupted to attend a code blue Administering medication involves critical responsibilities and decision-making that must be handled by a licensed nurse only.
A client is being treated for pulmonary hypertension. The nurse knows that the involvement of nursing, pharmacy, cardiology, physical therapy, and nutritional services is an example of which of the following approaches?
Rationale:
D: interdisciplinary
The collaboration between nursing, pharmacy, cardiology, physical therapy, and nutritional services exemplifies an interdisciplinary approach. This strategy promotes comprehensive care by integrating diverse expertise to address the complex needs of clients with pulmonary hypertension effectively.
A: continuity of care
Continuity of care focuses on consistent patient management over time rather than the collaborative efforts of various professionals. It emphasizes ongoing relationships rather than teamwork across disciplines.
B: case management
Case management centers on coordinating care for individual patients, often through a single provider or manager. It does not inherently involve the diverse participation of multiple specialized services.
C: quality improvement
Quality improvement relates to enhancing healthcare services and outcomes through systematic evaluation. This option does not specifically address the collaborative and multifaceted nature of care provision among different specialties.
The nurse is working with an unlicensed assistive personnel (UAP) in the medical-surgical unit. Which client should be assigned to the UAP?
Rationale:
D: A client who is post-op day 2 following a laparoscopic hernia repair and gets up to the chair for meals. This client is stable and can safely be assisted by a UAP for mobility and basic needs.
A: a client with cervical cancer who has an internal radiation implant. This client requires specialized care and monitoring due to the risks associated with radiation therapy, necessitating a nurse's expertise.
B: a client who is receiving blood as treatment for hypovolemic shock. Close observation is critical during blood transfusions to identify any adverse reactions quickly, requiring a nurse's attention.
C: a client who had an abdominal wound dehiscence 24 hours earlier and requires dressing changes. This situation involves potential complications that demand skilled nursing assessment and intervention beyond the UAP's capabilities.
The nurse reports to work and finds that a client from the previous day has been assigned to another nurse. The nurse had a great rapport with the client and wonders how he did during the night. She decides to look at the client's chart to read the progress notes. Which statement is correct regarding the nurse's actions?
Rationale:
The nurse is violating HIPAA regulations and should not be accessing the client's chart. Accessing a client's medical records without a professional need or consent constitutes a breach of confidentiality and privacy laws.
A: She should go to the client's room and see how he is doing. Visiting the client without being assigned to their care disregards professional boundaries and could disrupt the continuity of care.
B: She has legal access to the client's chart since she was involved in his care. Prior involvement does not grant unlimited access; legalities require a current, legitimate reason for chart review.
D: She should wait and ask the other nurse how the client is doing and not view the client's chart. Consulting the assigned nurse respects patient privacy, but accessing the chart remains unauthorized in this context.
The school nurse is monitoring the diet of a child with cystic fibrosis. Which type of diet would the family be advised to follow?
Rationale:
A high fat, high calorie diet is advised for a child with cystic fibrosis to meet their increased energy requirements and to support healthy growth and development. This diet helps to compensate for malabsorption issues associated with the condition.
A: low calorie, high fiber This option fails to address the increased caloric needs of children with cystic fibrosis, which can hinder proper growth and health maintenance.
B: low fiber, low fat A low fat diet does not provide the necessary caloric density required for children with cystic fibrosis, risking inadequate nutritional intake and growth.
C: low sodium, gluten free While some children may require gluten-free diets, a low sodium option neglects the need for increased caloric and fat intake for cystic fibrosis management.
A nurse manager is educating a group of nursing students about the Patient's Bill of Rights. The nurse knows that the student nurses have an understanding of the bill when one of the nurses makes which statement?
Rationale:
Clients have the right to a quick and objective review of any claim that they levy against a health care facility, physician, or health care plan. This statement accurately reflects a key component of the Patient's Bill of Rights, which emphasizes the importance of fair treatment and the ability to address grievances in a timely manner.
A: Clients have the right to view their medical records but may not copy any of the information contained in the records. This statement misrepresents the rights, as clients can often request copies of their records under specific regulations.
B: Clients wavenumber be declined care at an emergency department or need preauthorization for care if they do not have premium-level insurance. This statement contradicts the Emergency Medical Treatment and Labor Act, which mandates care regardless of insurance status.
D: It is the admitting nurse's job to verify the client's past medical history, medications, and treatments, even if the client refuses to cooperate in giving the information. This statement overlooks the importance of patient cooperation and informed consent in healthcare practices.
An external weather disaster has flooded the emergency department with several new clients. Which client should the nurse see first?
Rationale:
The client complaining of chest pain and nausea who is diaphoretic should be seen first. This client exhibits signs of a potential cardiac event, which requires immediate assessment and intervention to prevent life-threatening complications. Prioritizing clients based on severity is crucial in emergency situations, making this the most critical case.
B: the client with a simple fracture of the radius from a fall on a staircase presents a manageable injury that, while painful, does not indicate an immediate threat to life or health.
C: the client complaining of slight redness and itching at the IV site in his hand reflects a minor complication that can be addressed after more urgent cases, as it poses minimal risk.
D: the client presenting with a sprained ankle from a tree branch falling on him suffers from a non-life-threatening injury, which can be treated after more serious conditions are stabilized.
A newly graduated nurse has completed hospital orientation and has just started working with her own clients. Which of the following assignments is most appropriate for this nurse?
Rationale:
A newly graduated nurse should be assigned to a client who had a negative heart catheterization the day before.
This option is appropriate as the client’s condition is stable and requires monitoring rather than advanced interventions. The recent procedure means the nurse can safely manage assessments and support, while gaining experience in post-procedure care without the complexities of critical or acute situations.
A: a nonverbal client hospitalized for seizures. This assignment demands advanced communication skills and crisis management, which may overwhelm a newly graduated nurse lacking experience with such high-acuity patients.
B: a client undergoing peritoneal dialysis at the bedside. This task involves specialized skills and knowledge about dialysis procedures that a new nurse may not yet possess, posing potential risks to the client.
D: an elderly client who just returned from surgery for a below-the-knee amputation. Post-operative care requires advanced assessment skills and critical thinking, which may be challenging for a newly graduated nurse to perform effectively.