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A nurse caring for an oncology client notes the client is receiving a vesicant chemotherapy medication via intravenous (IV) infusion. Which assessment finding would warrant immediate action by the nurse?
- A. An inflamed and sore mouth
- B. Nausea and vomiting
- C. Pain and increasing edema at the infusion site
- D. Abdominal pain
Correct Answer: C
Rationale: Pain and edema at the infusion site (C) suggest extravasation of vesicant chemotherapy, a medical emergency requiring immediate cessation and intervention. Sore mouth (A), nausea (B), and abdominal pain (D) are common side effects, not urgent.
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The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
The charge nurse is planning client care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following clients would be most appropriate to assign to the LPN?
- A. A client requiring assistance picking out low potassium foods.
- B. A client requesting to leave the facility against medical advice (AMA).
- C. A client needing several prescriptions called into the local pharmacy.
- D. A client requesting breakthrough intravenous push (IV) pain medicine.
Correct Answer: A
Rationale: Assisting with low potassium food choices (A) is within the LPN’s scope, involving reinforcement of dietary teaching. AMA requests (B) and IV pain medication (D) require RN judgment, and calling prescriptions (C) may involve complex coordination.
The nurse notices an unlicensed assistive personnel (UAP) passing by several call lights during the shift. Which initial action should the nurse take?
- A. Approach the UAP about the behavior.
- B. Report unsafe behavior to the charge nurse.
- C. File an incident report due to safety risk.
- D. Ask another UAP to help cover this UAP's patient load.
Correct Answer: B
Rationale: Approaching the UAP (B) initially allows for clarification and correction of the nurse can address the behavior, promoting teamwork and addressing potential safety issues.. Reporting to the charge nurse (A) or filing an incident report (C) escalates prematurely. Assigning another UAP (D) does not address the root cause.
The nurse in the emergency department (ED) is caring for a client who intentionally overdosed on their prescribed lithium. The nurse plans on initially
- A. developing a therapeutic rapport with the client.
- B. inserting a peripheral vascular access device.
- C. obtaining the client’s vital signs.
- D. collecting a serum lithium level on the client.
Correct Answer: B
Rationale: Inserting a peripheral vascular access device (B) is the initial priority in a lithium overdose to enable rapid administration of fluids or medications to stabilize the client. Vital signs (C) and lithium levels (D) follow, and rapport (A) is secondary to medical stabilization.
The nurse is caring for a client who is postoperative following a lobectomy. The client is receiving fentanyl via an epidural. The nurse should monitor the client for which complication?
- A. Diarrhea
- B. Hypotension
- C. Hyperventilation
- D. Urinary incontinence
Correct Answer: B
Rationale: Epidural fentanyl can cause hypotension (B) due to vasodilation, a serious complication requiring monitoring. Diarrhea (A), hyperventilation (C), and urinary incontinence (D) are less common or unrelated.