Nur 004. Exam Success Guaranteed: Comprehensive Study Guides

3 The registered nurse is caring for multiple clients on a busy surgical unit and should delegate which action to the unlicensed assistive personnel? 1. Assist client, post hip fracture repair, to the bathroom 2. Check the appearance of client's wound 3. If client tolerates oral liquids, discontinue nasogastric tube 4. Offer orange juice to client if bedside glucose reading is 70 mg/dL (3.9 mmol/L) 1 Which statements related to ethical nursing practices are correct? Select all that apply. 1. Accountability is documenting that the nurse administered the wrong medication 2. Autonomy is informing the client of the decision the family made for the client 3. Confidentiality is respecting a client's request to keep suicidal ideation a secret 4. Justice is providing the same cardiac care to a homeless person as a businessperson 5.Nonmaleficence is reporting abuse for a client with Alzheimer disease 1,4,5 A major earthquake has occurred. Local gas lines and water pipes are breaking with resulting fires and flooding in collapsed buildings. Multiple victims come to the triage area. Which client would the nurse care for first? 1. Charred leathery skin over entire back, chest, and legs 2. Client shivering from sitting in water until rescued 3. Diabetic client who was unable to take insulin today 4. High-pitched, crowing inspiratory respirations 4 The charge nurse on a medical-surgical step-down unit is responsible for making assignments. Which client is most appropriate to assign to a new graduate nurse who is still in orientation? 1. 65-year-old client 1 day postoperative left femoral-popliteal bypass graft surgery with a diminished pedal pulse 2. 66-year-old client admitted for hypertensive crisis 2 days ago; blood pressure currently 180/102 mm Hg; reports headache and blurred vision 3. 75-year-old client with an ischemic stroke transferred from the intensive care unit 1 hour ago; unresponsive with right-sided paralysis 4. 78-year-old client with diabetes and cellulitis of the left foot; requires frequent dressing changes due to excessive drainage 4 An unaccompanied 16-year-old female comes to the emergency department with severe abdominal pain and vomiting. The minor has a temperature of 102.2 F (39 C) and a pulse of 120 /min and is lethargic. The parents are out of town, and no guardians could be reached. How should the care be handled? 1. Administer care until parents or guardians can be reached 2. Keep the minor but without giving care until parents or guardians can be reached 3. Perform a pregnancy test to see if the minor qualifies as an emancipated minor 4. Provide health care and follow-up advice but do not give any direct care