the emergency triage nurse should perform which action upon receiving the history that a client has a severe cough fever night sweats and body wasting

NCLEX-PN

Nclex Questions Management of Care

1. What action should the emergency triage nurse take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting?

A. Place the client in isolation until further assessment is completed.
B. Seclude the client from other clients and visitors.
C. Perform no intervention until test results confirm a diagnosis.
D. Don personal protective equipment immediately.

Correct answer: B

Rationale: The correct action for the emergency triage nurse to take upon receiving the history that a client has a severe cough, fever, night sweats, and body wasting is to seclude the client from other clients and visitors. These symptoms are suggestive of tuberculosis, a highly infectious disease. By secluding the client, the nurse can prevent the potential spread of the infection to others. Donning personal protective equipment, including gown, gloves, and a mask, is crucial when providing care to the client, but the immediate priority is to prevent the spread of infection by isolating the client. Placing the client in isolation until further assessment is completed ensures that the client is kept away from others until a proper diagnosis and treatment plan can be established, reducing the risk of transmission. Performing no intervention until test results confirm a diagnosis is inappropriate as immediate isolation is necessary in suspected cases of highly infectious diseases like tuberculosis.

2. An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?

A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
B. The client will maintain a blood glucose level within normal range limits today.
C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
D. The client will maintain a blood glucose level within normal limits throughout my shift.

Correct answer: C

Rationale: The correct answer is 'The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.' This outcome is specific, measurable, and aligns with the goal of managing diabetes mellitus. Choice A is correct because it provides a clear target range (70-110) and includes adherence to facility policy, making it precise and goal-oriented. Choice B lacks specificity on the timeframe, and Choice D is vague in defining the target blood glucose range. In nursing care plans, outcomes should be well-defined, achievable, and measurable to effectively monitor the client's progress in managing their condition.

3. Which statement about clinical pathways is inaccurate?

A. They require daily updates.
B. They illustrate the expected client response to their diagnosis.
C. The objective is improvement or discharge from the facility.
D. They are evidence-based.

Correct answer: A

Rationale: The correct answer is that clinical pathways do not necessarily require daily updates. Clinical pathways can be customized to be updated daily, weekly, or at other intervals based on patient needs and facility protocols. Choice A is inaccurate as daily updates are not always mandatory for clinical pathways. Choices B, C, and D are accurate features of clinical pathways: they depict the expected client response to the diagnosis, aim for improvement or discharge, and are grounded in evidence-based practices to ensure optimal care.

4. The nurse on the 3-11 shift is assessing the chart of a client with an abdominal aneurysm scheduled for surgery in the morning and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?

A. Call the surgeon and ask them to see the client to clarify the information
B. Explain the procedure and complications to the client
C. Check the physician's progress notes to see if understanding has been documented
D. Check with the client's family to see if they understand the procedure fully

Correct answer: A

Rationale: The most appropriate action in this scenario is to call the surgeon and ask them to see the client to clarify the information. It is the responsibility of the physician to explain and clarify the procedure to the client, ensuring informed consent. Answer B is incorrect as nurses should not provide detailed medical explanations beyond their scope of practice. Answer C is incorrect as the physician's notes may not capture the client's current understanding accurately. Answer D is incorrect because the client's own understanding, not the family's, is crucial for informed decision-making regarding the surgery.

5. What should be the first action upon the discovery of an electrical fire?

A. Disconnect the electrical power if it can be done safely
B. Smother the source with an object like a blanket
C. Saturate the source with water or another liquid
D. Immediately activate the fire alarm

Correct answer: A

Rationale: The correct initial action upon discovering an electrical fire is to disconnect the electrical power if it can be done safely. This helps prevent the fire from spreading through the electrical system. Smothering the fire with a blanket is not recommended for electrical fires as it can fuel the fire. Saturating the source with water or other liquids is also not advised as it can lead to electric shock or spread the fire. Activating the fire alarm is important, but it should be done after disconnecting the power to prevent further escalation of the fire.