all of the following clients are in need of an emergency assessment except

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. All of the following clients are in need of an emergency assessment except:

A. a bleeding client who has an injury from falling debris.
B. an unresponsive client.
C. a client with an old injury.
D. a pregnant woman with imminent delivery.

Correct answer: C

Rationale: The correct answer is 'a client with an old injury.' Emergency assessments are required for immediate and life-threatening situations. Clients A, B, and D are in need of emergency assessments due to their critical conditions. Choice C, a client with an old injury, does not require an emergency assessment as it is not an acute or life-threatening situation. While the client with an old injury may still need medical attention, it does not necessitate an emergency assessment as the condition is not currently life-threatening or in need of immediate intervention.

2. A client with cancer is transported to the radiology department for a bone scan to determine whether the cancer has metastasized to bone. While the client is in the radiology department, the client's wife arrives for a visit and asks what test is being performed on the client. What should the nurse tell the wife?

A. A bone scan is being performed.
B. She can read the client's medical record to determine what the health care provider prescribed.
C. The radiology department is not clear as to which test has been prescribed.
D. She will have to discuss the prescribed test with the client.

Correct answer: D

Rationale: In healthcare, confidentiality is crucial. Without the client's consent, nurses cannot disclose confidential information to anyone else, even to family members. Therefore, the appropriate response is to inform the client's wife that she will have to discuss the test with the client directly. It is not appropriate to disclose sensitive medical information without the client's permission. Offering the wife to read the medical record is a violation of privacy and confidentiality. Indicating that the radiology department is unclear about the prescribed test is inaccurate and does not uphold confidentiality. Moreover, it is not the responsibility of another department to disclose medical information; it is the duty of the healthcare provider and the client to discuss such matters.

3. Which of the following tasks are appropriate for an LPN to perform?

A. Adjusting the cervical traction device of a 68-year-old client as instructed by the charge nurse.
B. performing operation on a woman in labour
C. Assessing a 36-year-old man newly admitted for chest pain.
D. Obtaining an occult blood sample from a 16-year-old client with ulcerative colitis.

Correct answer: D

Rationale: Tasks appropriate for an LPN to perform include teaching, obtaining samples, and documenting. LPNs can educate clients on care practices, such as teaching a new mother how to care for her baby. Obtaining samples, like an occult blood sample, falls within the scope of an LPN's responsibilities. Assessments, especially initial assessments, should be conducted by a registered nurse or physician, making option C incorrect. Adjusting devices like a cervical traction device should be done based on direct orders from prescribing providers, not charge nurses, making option A inappropriate for an LPN's role.

4. A nurse is assigned to care for four clients. Which client should the nurse assess first?

A. A client scheduled for a colonoscopy
B. A client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask
C. A client preparing for discharge after surgery
D. A client requiring a tube feeding through a gastrostomy tube

Correct answer: B

Rationale: The correct answer is a client with a tracheostomy who is receiving humidified oxygen via a tracheostomy mask. Airway management is always the priority in nursing care. Assessing this client first ensures that their airway is clear and oxygenation is adequate. Clients with compromised airways need immediate attention to prevent respiratory distress or failure. The other clients do not have immediate airway concerns and represent lower priorities in this scenario. Therefore, the nurse should prioritize assessing the client with the tracheostomy and oxygen therapy to maintain airway patency and adequate oxygenation.

5. A nurse is taking a morning break with the unit secretary in the nurses' lounge. The unit secretary says to the nurse, 'I read in Mr. Gage's medical record that he has gonorrhea.' How should the nurse respond to the secretary?

A. Yes, he does, but be sure not to discuss this with anyone else.
B. Yes, that's why we've imposed contact precautions.
C. We can't discuss a client's medical condition.
D. Oh, really? I didn't see that!

Correct answer: C

Rationale: A client's medical condition is confidential and should never be discussed with anyone other than the client and the client's healthcare provider. Therefore, the nurse must tell the unit secretary that the client's condition is not to be discussed. Choices A and B confirm the client's disease, which is inappropriate as it breaches patient confidentiality. Choice D promotes further discussion of the client's condition, which is also inappropriate. The correct response is to firmly state, 'We can't discuss a client's medical condition,' to uphold patient privacy and confidentiality.