After receiving report at the start of the evening shift, which of the following clients should the nurse
attend to first?
(a) A 34-year-old man
... [Show More] undergoing treatment for non-Hodgkin lymphoma with a potassium level of 7.5
mEq/L.
(b) A 21-year-old woman with sickle cell anemia with pain of 6 on a scale of 1-10.
(c) A 55-year-old woman with ovarian cancer waiting to be discharged.
(d) A 72-year-old man with chronic obstructive pulmonary disease (COPD) and a pulse oximetry of
96% on room air. - Correct answer: (a) A 34-year-old man undergoing treatment for non-Hodgkin
lymphoma with a potassium level of 7.5 mEq/L.
Rationale: Hyperkalemia is a potentially serious condition that, in a client undergoing treatment for
non-Hodgkin lymphoma, could indicate tumour lysis syndrome. Patient (b) should be attended to, but
her condition is not as urgent. Patients (c) and (d) do not require immediate attention.
A 34-year-old woman who developed Stevens-Johnson syndrome while undergoing treatment with
carbamazepine (Tegretol) is being transferred in stable condition from the intensive care unit to the
medical unit. There are 4 beds available. The nurse knows the best choice of roommates for this
client is which of the following?
(a) A 40-year-old man with methicillin-resistant Staphylococcus aureus (MRSA).
(b) A 28-year-old woman diagnosed with diarrhea.
(c) A 72-year-old man with fever of unknown origin.
(d) A 68-year-old woman with atrial fibrillation . - Correct answer: (d) A 68-year-old woman with atrial
fibrillation.
Rationale: A client with Stevens-Johnson syndrome is likely to have severe skin integrity issues,
including blistering and skin shedding, which can place the client at high risk for infection. Atrial
fibrillation is not an infectious process. All other patients may be an infection risk for an individual with
altered skin integrity.
A 72-year-old man who had a stroke is being transferred from a medical unit to a rehabilitation centre.
The nurse case manager is assisting in the process. The nurse knows that the goals of case
management include which of the following? Select all that apply.
(a) Improving the coordination of care
(b) Increasing referrals to local organizations
(c) Reducing the fragmentation of care
(d) Discharging clients quickly - Correct answer: (a) Improving the coordination of care; and (c)
Reducing the fragmentation of care
Rationale: Some of the primary goals of case management are to improve the coordination of care
and to reduce fragmentation of care. The other options are not goals of case management.
A pregnant woman at 15 weeks' gestation is scheduled for an amniocentesis. As the client is being
prepped for the procedure, it becomes clear to the nurse that the client doesn't fully understand the
risks and benefits associated with the procedure. Which of the following describe the nurse's role in
obtaining informed consent? Select all that apply.
(a) Explain the risks and benefits associated with the procedure.
(b) Describe alternatives to the procedure.
(c) Witness the client's signature on the consent form.
(d) Advocate for the client by ensuring she is making an informed decision. - Correct answer: (c)
Witness the client's signature on [Show Less]