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While caring for a client who requires a mechanical ventilator for breathing, the high-pressure alarm goes off on the ventilator. What is the first action the nurse should perform?
- A. Disconnect the client from the ventilator and use a manual resuscitation bag.
- B. Perform a quick assessment of the client's condition.
- C. Call the respiratory therapist for help.
- D. Press the alarm reset button on the ventilator.
Correct Answer: B
Rationale: A high-pressure alarm suggests obstruction or resistance, so assessing the client’s condition (B) first identifies the cause (e.g., tube kinking, secretions). Disconnecting (A), calling for help (C), or resetting (D) without assessment risks harm or delays resolution.
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The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who
- A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
- B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
- C. has a substance use disorder and refuses to attend group therapy for the second time.
- D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
Correct Answer: A
Rationale: Pacing and mumbling in psychosis (A) suggest agitation or worsening symptoms, posing a safety risk requiring immediate follow-up. Increased hand washing (B), therapy refusal (C), and abuse allegations (D) are less urgent, as they are chronic or procedural.
A nurse observes a colleague failing to perform hand hygiene before entering multiple client rooms and administering medications. What is the most appropriate action by the nurse?
- A. Confront the colleague immediately in a client's room to stop the behavior
- B. Document the incident in the nurse's notes while monitoring for further issues
- C. Immediately report the behavior to the nurse manager for follow-up
- D. Assume the colleague is having a busy shift, and address it at a later time
Correct Answer: C
Rationale: Reporting to the nurse manager (C) ensures prompt follow-up on a serious infection control breach that risks client safety. Confronting in a client’s room (A) is unprofessional, documenting without action (B) delays intervention, and assuming busyness (D) ignores the safety violation.
The nurse is caring for a child in the emergency department (ED) who sustained a bite from a rabid animal. The nurse should take which initial action
- A. Complete a detailed wound assessment
- B. Cleanse the wound with soap and water
- C. Obtain a prescription for an antibiotic
- D. Report the bite to animal control
Correct Answer: B
Rationale: Cleansing the wound with soap and water (B) is the initial action for a rabid animal bite to reduce viral load and infection risk, per CDC recommendations. Wound assessment (A), antibiotics (C), and reporting (D) follow initial cleaning.
The nurse is caring for a client who expresses feeling self-conscious about their hair and states they would like to wash it before undergoing diagnostic tests and procedures. How should the nurse prioritize the client's care?
- A. Offer the client a cap or scarf to cover their hair and suggest washing it after the diagnostic tests are complete.
- B. The nurse should schedule the testing and meal planning first and complete hygiene as time permits.
- C. Perform the dressing changes first, schedule testing, counsel, and complete hygiene last.
- D. Arrange to wash the client's hair first, perform hygiene, and then complete the diagnostic testing and counseling.
Correct Answer: A
Rationale: Offering a cap/scarf and suggesting washing later (A) addresses the client’s emotional needs while prioritizing timely diagnostics, ensuring medical care is not delayed. Scheduling tests first (B), prioritizing dressings (C), or washing hair first (D) either delays care or ignores efficiency.
The nurse is caring for a patient recovering from a client who has had cardiac catheterization via the right femoral artery. The nurse notes stable vital signs one hour post-procedure but cannot palpate the right pedal pulse. Which action would be the nurse's highest priority action?
- A. Assess bilateral lower extremity capillary refill
- B. Notify the severity physician
- C. Place bed in the Trendelenburg position
- D. Recheck pedal pulse with doppler
Correct Answer: B
Rationale: Absence of a pedal pulse post-catheterization (B) suggests vascular occlusion, requiring urgent physician notification to prevent limb ischemia. Checking capillary refill (A) or using Doppler (D) is secondary. Trendelenburg (C) is inappropriate for this issue.