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A client who has been waiting for several hours in the clinic waiting room suddenly begins to shout, 'I need some attention and I need it now!' How should the nurse respond initially?
- A. Tell the client to be quiet and that she will be seen as soon as possible
- B. Immediately call security and the police
- C. Talk with the woman and determine her immediate needs
- D. Explain to the woman how busy the doctors are and that she will be seen soon
Correct Answer: C
Rationale: Engaging the client to assess her needs de-escalates agitation and addresses concerns. Silencing, calling security, or explaining delays may escalate tension.
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A client scheduled for a computerized axial tomography (CAT) using a contrast medium scan of the brain should be assessed for:
- A. Claustrophobia
- B. Iodine sensitivity
- C. Liver function
- D. Metallic implants
Correct Answer: B
Rationale: Contrast medium often contains iodine, so assessing for iodine sensitivity prevents allergic reactions. Claustrophobia, liver function, and implants are secondary concerns.
The nurse is observing a staff member collecting a sputum specimen from a client with active tuberculosis. The nurse should intervene if the staff member is observed
- A. leaving unused supplies in the client's room after the procedure
- B. putting on clean gloves before putting on a protective gown
- C. leaving a dedicated, disposable stethoscope in the client's room
- D. putting on an N95 respirator mask and face shield before entering the client's room
Correct Answer: A
Rationale: Leaving supplies (A) in a TB room risks contamination. Gloves before gown (B), dedicated stethoscope (C), and N95 with face shield (D) are appropriate.
The clinic nurse is planning to assess the visual acuity of a 6-year-old. Which method is the best way to assess visual acuity in this child?
- A. Have the child identify different objects using Allen figure testing cards
- B. Have the child point in the direction each letter is facing on a tumbling E chart
- C. Have the child read letters on a Snellen chart while standing 10 ft (3 m) away
- D. Have the child view a set of Ishihara colored cards one at a time
Correct Answer: B
Rationale: The tumbling E chart (B) is age-appropriate for a 6-year-old, who may not know letters. Allen cards (A) are for younger children, Snellen at 10 ft (C) is non-standard, and Ishihara (D) tests color vision.
A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first
- A. support the planning committee and post the new schedule
- B. explore how the planning committee evaluated barriers to the plan
- C. design a different approach to deliver care with fewer staff
- D. retain the previous staffing pattern for another 6 months
Correct Answer: B
Rationale: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm, as uterine atony is the primary cause of bleeding in the first hour after delivery.