Nokea
A client has used a condescending tone towards the nurse, subsequently angering the nurse. Which response by the nurse would be most therapeutic?
- A. That tone of voice makes me feel upset.'
- B. You make me angry when you talk like that.'
- C. Are you trying to upset me?'
- D. Why do you use that tone of voice with me?'
Correct Answer: A
Rationale: Expressing feelings using 'I' statements (A) is therapeutic, promoting open communication without blame. Blaming the client (B), assuming intent (C), or questioning their tone (D) escalates conflict and is non-therapeutic.
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The nurse is caring for assigned clients. Which of the following actions would reflect effective care coordination? Select all that apply.
- A. Arranging for an interdisciplinary conference
- B. Consulting with case management for a discharge plan
- C. Initiating appropriate outpatient referrals
- D. Performing post-discharge phone calls
- E. Implementing transmission-based precautions
Correct Answer: A, B, C, D
Rationale: Effective care coordination includes interdisciplinary conferences (A), case management for discharge (B), outpatient referrals (C), and post-discharge follow-up (D). Transmission precautions (E) are infection control, not care coordination.
The nurse is reviewing their written documentation and notices an error. The nurse should correct the error by Select all that apply.
- A. drawing a line through the erroneous documentation.
- B. using correction tape and write over the error.
- C. writing over the error in darker ink.
- D. completely black out the error with a black marker.
- E. discarding the documentation in the trash and starting over.
- F. writing your initials, date, and time above the erroneous documentation with the word 'error.'
Correct Answer: A, F
Rationale: Correcting documentation errors involves drawing a single line through the error (A) and initialing, dating, and noting 'error' (F). Correction tape (B), writing over (C), blacking out (D), or discarding (E) are incorrect and violate documentation standards.
The nurse reviews the client's emergency department (ED) triage note. Which action should the nurse take first? See the image below.
- A. Establish continuous cardiac monitoring
- B. Obtain an order for a complete metabolic panel
- C. Obtain a prescription for acetaminophen (APAP)
- D. Apply a cool compress to the client's forehead
Correct Answer: A
Rationale: This client is showing manifestations of digitalis toxicity. The client's bradycardia, anorexia, and vomiting are classic signs of this potentially fatal toxicity. The nurse should immediately establish continuous cardiac monitoring because, if untreated, digitalis toxicity may cause multifocal premature ventricular contractions (PVCs) that may transition to ventricular tachycardia or ventricular fibrillation. Because of digitalis' ability to have a negative chronotropic effect, bradycardia is often seen in toxicity.
The nurse is caring for a client with suspected meningitis. Which priority action should the nurse take following a lumbar puncture (LP) procedure?
- A. Assess the gag reflex
- B. Elevate the head of the bed to 30 degrees
- C. Encourage oral fluid intake
- D. Assess the client for Brudzinski sign
Correct Answer: C
Rationale: Encouraging oral fluid intake (C) post-lumbar puncture helps prevent spinal headache and supports recovery. Assessing gag reflex (A) is unrelated, elevating the head (B) depends on provider orders, and Brudzinski’s sign (D) is assessed before the procedure to diagnose meningitis, not after.
The nurse manager receives a complaint from a client's family member. The nurse manager should take which initial action?
- A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately
- B. Speak with the night shift nurse regarding the complaint and discuss the care provided
- C. Assess the complaint and clarify the details with the family member and client
- D. Take note of the complaint and place it in the applicable employee's file
Correct Answer: C
Rationale: Assessing the complaint and clarifying details with the family and client (C) is the initial step to understand the issue and ensure accurate resolution. Directing the charge nurse (A), speaking with the nurse (B), or filing the complaint (D) are premature without first gathering facts.