Nokea
A health care provider is screaming at the nurse in the hallway. 'Why didn't you get that surgery scheduled sooner?' What is the best response by the nurse?
- A. I am so sorry; I will get this fixed and schedule the surgery immediately
- B. I am uncomfortable with your tone, please excuse me while I locate my supervisor
- C. I delegated this task to the unlicensed assistive personnel: please follow up with them.
- D. I think you are overreacting, you should have specified the day and time
Correct Answer: B
Rationale: Responding calmly and redirecting to a supervisor de-escalates the situation professionally while addressing the inappropriate tone. Accusing the provider of overreacting is confrontational and unprofessional.
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A client with hypertension and type 2 diabetes has recently started taking chlorthalidone. Which report by the client is most concerning to the nurse?
- A. Dizziness on standing
- B. Fasting blood glucose of 180 mg/dL (10.0 mmol/L)
- C. Presence of muscle cramps
- D. Sunburn on both arms
Correct Answer: A
Rationale: Dizziness on standing suggests orthostatic hypotension, a serious side effect of chlorthalidone, which can lead to falls. Elevated glucose and muscle cramps are concerning but less urgent, and sunburn is unrelated.
Which information should be included in the nurse's shift report?
- A. The client's sodium level is 147 mEq/L
- B. The client's potassium level is 4 mEq/liter
- C. The client's urine output was 1500 cc in 5 hours
- D. The client is to receive another dose of Lasix at 10 PM
Correct Answer: C
Rationale: Although all of these may be correct information to include in report, the essential piece would be the urine output, as it indicates the client's fluid status and response to treatment.
The nurse is talking with a client with obsessive-compulsive disorder. When the client performs ritualistic behaviors, the nurse should recognize that the client
- A. is hearing voices
- B. is trying to control feelings of anger
- C. has an intense desire to control the environment
Correct Answer: C
Rationale: Ritualistic behaviors in OCD are driven by an intense need to control the environment or reduce anxiety through repetitive actions. They are not related to hearing voices or controlling anger, which are more associated with other disorders.
The nurse is discussing health concerns with a group of adolescent girls. When discussing genital warts caused by condyloma acuminata (HPV), the nurse should emphasize that the organism increases the risk of which condition?
- A. Infertility
- B. Congenital anomalies
- C. Cervical cancer
- D. Uterine prolapse
Correct Answer: C
Rationale: Certain HPV strains, including those causing genital warts, are linked to cervical cancer, necessitating regular screening. Infertility, anomalies, or prolapse are not directly related.
A client has been admitted with a catheter-associated, vancomycin-resistant enterococcal bacteremia. Which interventions should the nurse implement? Select all that apply.
- A. Keep dedicated equipment for client
- B. Perform hand hygiene before exiting the room
- C. Place a 'No Visitors' sign on the client's door
- D. Wear a face mask when in the room
- E. Wear an isolation gown when providing direct care
Correct Answer: A,B,E
Rationale: Dedicated equipment, hand hygiene, and an isolation gown prevent the spread of vancomycin-resistant enterococcus. A 'No Visitors' sign is unnecessary, and a face mask is not required unless droplet precautions are indicated.