Nokea
The nurse is caring for assigned clients. The nurse should initially assess the client who has
- A. left pulmonary empyema, a temperature of 102.4°F (39.1°C), and a pulse of 104.
- B. gentle bubbling in the water seal chamber of their chest tube when exhaling.
- C. a right pleural effusion and has decreased tactile fremitus in the right lobe.
- D. pneumonia and has a pulse oximetry of 90% while on 4 liters of nasal cannula oxygen.
Correct Answer: A
Rationale: Fever (102.4°F) and tachycardia (104) in empyema (A) suggest worsening infection or sepsis, requiring immediate assessment. Chest tube bubbling (B) is normal, pleural effusion findings (C) are expected, and 90% saturation (D) is stable with oxygen.
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The nurse has received the following information about assigned clients. The nurse should first assess the client with
- A. pancreatitis who has developed bruising around the umbilicus.
- B. a capillary blood glucose of 159 mg/dL (8.83 mmol/L) [70-110 mg/dL; 4-6 mmol/L] while receiving total parenteral nutrition.
- C. a blood pressure of 156/92 mmHg who sustained an ischemic stroke six hours ago.
- D. stable angina reporting headache while receiving nitroglycerin via transdermal patch.
Correct Answer: A
Rationale: Umbilical bruising in pancreatitis (A) suggests Cullen’s sign, indicating possible retroperitoneal hemorrhage, a life-threatening emergency. Mild hyperglycemia (B), elevated BP post-stroke (C), and nitroglycerin headache (D) are less urgent, as they are expected or manageable.
The nurse manager is completing an annual performance evaluation of a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply.
- A. The nurses’ bar-code medication administration scan rate
- B. The number of times the nurse has been absent or tardy
- C. The nurse achieving a national certification
- D. The nurses’ performance compared to other staff nurses
- E. The number of medication errors the nurse has self-reported.
Correct Answer: A, B, C, E
Rationale: Bar-code scan rate (A), absences/tardiness (B), national certification (C), and self-reported errors (E) are objective metrics for evaluation. Comparing to other nurses (D) is subjective and biased, inappropriate for inclusion.
The nurse is caring for assigned clients. The nurse should initially follow up on the client who is
- A. three days postoperative following transsphenoidal hypophysectomy and has a temperature of 101°F (38.3°C).
- B. connected to a chest tube for a pneumothorax and has absent breath sounds on the affected side.
- C. receiving albuterol via a nebulizer and telling the unlicensed assistive personnel they feel nervous.
- D. receiving peritoneal dialysis and reports cramping as the solution is being instilled.
Correct Answer: B
Rationale: Absent breath sounds with a chest tube for pneumothorax (B) indicate a life-threatening complication, such as tube dislodgement or re-collapse, requiring immediate assessment. A fever post-hypophysectomy (A) suggests infection but is less urgent. Nervousness from albuterol (C) is a common side effect, and cramping during dialysis (D) is less critical unless severe.
The nurse is caring for assigned clients. The nurse should initially
- A. administer prescribed antibiotics to a client with bacterial meningitis.
- B. reposition a client with chronic back pain who reports pain rated 6/10 on the Numerical Rating Scale.
- C. remove a nitroglycerin prosthetic transdermal patch for a client with chronic angina.
- D. assess a client who had a coronary artery bypass grafting (CABG) three days ago and has a serum glucose of 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 3.9-6.1 mmol/L].
Correct Answer: A
Rationale: Antibiotics for bacterial meningitis (A) are critical to prevent rapid deterioration. Repositioning for pain (B), removing nitroglycerin patch (C), and assessing glucose of 135 (D) are less urgent.
Which of the following clients should the nurse assess first when preparing to do initial rounds?
- A. The client with diabetes who is being discharged today.
- B. A 32-year-old female with a tracheostomy experiencing copious secretions.
- C. A 16-year-old scheduled for physical therapy this morning.
- D. An 80-year-old male with a decubitus ulcer that needs a dressing change.
Correct Answer: B
Rationale: Copious tracheostomy secretions (B) pose an immediate airway obstruction risk, requiring first assessment to ensure patency. Diabetes discharge (A), physical therapy (C), and ulcer dressing (D) are less urgent, as they do not threaten immediate airway compromise.