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A nurse must recommend clients for discharge in order to make room for several critically injured clients from a local disaster. Which of the following clients should the nurse recommend for discharge?
A A client who has cellulitis and is receiving oral antibiotics every 8 hr A client who has cellulitis and is receiving oral antibiotics every 8 hr has a mild to moderate infection that can be managed at home with proper wound care and medication adherence. The client does not require hospitalization unless there are signs of systemic infection or complications.
A rural community health nurse is developing a plan to improve healthcare delivery for migrant farmworkers. To identify health services data for this minority group, the nurse should gather information from which of the following sources?
C Department of Agriculture The Department of Agriculture is a federal agency that oversees agricultural production, food safety, nutrition, and rural development. It also collects and publishes data on migrant and seasonal farmworkers, such as their demographics, health status, and access to health care.
A nurse is reviewing the ABG values of a client. The client has a pH of 7.2, PaCO2 of 60 mm Hg, and HCO3 of 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances?
C Respiratory acidosis The client has respiratory acidosis because respiratory acidosis is characterized by a high PaCO2 (greater than 45 mm Hg) and a low pH (less than 7.35).
A charge nurse is speaking with the partner of a client. The partner states that the client is not receiving adequate care. Which of the following actions should the charge nurse take first to resolve the situation?
Ask the partner to list specific concerns This is correct because it shows respect and empathy for the partner and allows for clarification and communication of their expectations and needs. It also helps identify any gaps or misunderstandings in the client's care and facilitates problem-solving and resolution.
A nurse is caring for a client who is receiving positive end-expiratory pressure (PEEP) via mechanical ventilation. The nurse should monitor the client for which of the following adverse effects of PEEP?
B Tension pneumothorax. Tension pneumothorax is a life-threatening condition of air accumulation in the pleural space that causes increased intrathoracic pressure and compresses the lungs, heart, and great vessels. PEEP can increase the risk of tension pneumothorax by creating excessive positive pressure in the airways and alveoli.
A nurse administers an incorrect dose of medication to a client. The nurse recognizes the error immediately and completes an incident report. Which of the following facts related to the incident should the nurse document in the client's medical record?
Time the medication was given The time the medication was given is an essential fact related to the incident that should be documented in the client's medical record
A nurse in an emergency department is caring for a client who is unconscious and requires emergency medical procedures. The nurse is unable to locate members of the client's family to obtain consent. Which of the following actions should the nurse take?
Proceed with provision of medical care This is correct because it follows the principle of implied consent, which assumes that a reasonable person would consent to emergency treatment if they were able to do so. The nurse should document the circumstances and continue to search for family members or other sources of consent.
A nurse is providing information to a client immediately before his scheduled Romberg test. Which of the following statements should the nurse make?
D "I will be checking you once with your eyes open and once with them closed." The Romberg test involves checking the client's balance with their eyes open and then with their eyes closed.
During a change-of-shift report, a night shift nurse informs the day shift nurse that a newly admitted client was disoriented and combative during the night. Which of the following actions should the day shift nurse take?
Move the client to a room near the nurses' station Move the client to a room near the nurses' station: This is correct because it allows for close observation and supervision of the client, which can prevent injury and promote safety. It also facilitates frequent interaction and reassurance from the staff, which can reduce anxiety and agitation.
