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A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
- A. A client who has heart failure and peripheral edema
- B. A client who reports urinary burning and a temperature of 29.2° C (102.51 F)
- C. A client who has cirrhosis of the liver and bruising on their arms
- D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min
Correct Answer: D
Rationale: The correct answer is D because a new onset of atrial fibrillation with a heart rate of 152/min indicates a potentially life-threatening cardiac condition requiring immediate attention to prevent complications such as stroke or heart failure. Atrial fibrillation can lead to decreased cardiac output and increase the risk of blood clots forming in the heart. The high heart rate can also lead to hemodynamic instability. A prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is incorrect as heart failure with peripheral edema, while concerning, does not pose an immediate life-threatening risk compared to a new onset of atrial fibrillation.
Choice B is incorrect as urinary burning and a temperature of 29.2° C (102.51 F) may indicate a urinary tract infection, which is important but not as urgent as the cardiac issue in choice D.
Choice C is incorrect as bruising in a client with cirrhosis of the liver is concerning for potential bleeding disorders, but it is not
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A nurse is preparing to perform hand hygiene with an alcohol-based hand sanitizer. Which of the following actions should the nurse plan to take?
- A. Use hot water to rinse hand sanitizer off
- B. Dry hands with a reusable towel
- C. Rub hands together 20 seconds
- D. Rub hand sanitizer around rings on fingers
Correct Answer: D
Rationale: The correct answer is D: Rub hand sanitizer around rings on fingers. This is important because rings can harbor bacteria and viruses, and by rubbing hand sanitizer around them, the nurse ensures that all surfaces of the hands, including under the rings, are effectively sanitized. This action helps prevent the transmission of pathogens.
A: Using hot water to rinse hand sanitizer off is unnecessary and can actually be harmful as it can cause skin irritation.
B: Drying hands with a reusable towel is not recommended as it can harbor germs and compromise hand hygiene.
C: Rubbing hands together for 20 seconds is a good practice, but the specific action related to rings is more crucial.
E, F, G: No information provided.
A nurse is reviewing the medical history of a client who is listed for surgery. Which of the following findings places the client at risk for a complication of incisional hematoma forming?
- A. The client is underweight
- B. The client takes anticoagulant medications
- C. The client has urinary incontinence
- D. The client has peripheral vascular disease
Correct Answer: B
Rationale: The correct answer is B: The client takes anticoagulant medications. Anticoagulant medications inhibit blood clotting, increasing the risk of bleeding and hematoma formation at the surgical site. This poses a significant complication during and after surgery. Other choices are incorrect because being underweight (A), having urinary incontinence (C), and having peripheral vascular disease (D) do not directly increase the risk of incisional hematoma formation.
A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the 'E' in the NURSE mnemonic?
- A. It sounds like you are exhausted
- B. You have so much to deal with, how can I be of help to you?
- C. Tell me more about how you are feeling
- D. It is impressive how you have managed to deal with this situation
Correct Answer: A
Rationale: The correct answer is A. In the NURSE mnemonic, 'E' stands for empathy. By acknowledging the client's feeling of being overwhelmed and reflecting it back by saying "It sounds like you are exhausted," the nurse demonstrates empathy. This response shows understanding and validation of the client's emotions, which can help the client feel heard and supported.
Choice B focuses more on offering help without directly addressing the client's emotional state. Choice C is about exploring the client's feelings but does not directly acknowledge the expressed emotion of being overwhelmed. Choice D praises the client's coping skills but does not address the current emotional state of feeling overwhelmed.
A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include?
- A. Provide a dedicated area for the nurse to prepare medications
- B. Wait to document medications given to clients until the end of a shift
- C. Remove medications from automatic dispensing systems before they are reviewed by pharmacists
- D. Prepare medications for multiple clients at the same time
Correct Answer: A
Rationale: Correct Answer: A - Provide a dedicated area for the nurse to prepare medications.
Rationale: Providing a dedicated area for medication preparation helps reduce distractions and promotes focus, decreasing the likelihood of errors. This setup allows for organization and prevents cross-contamination. It also encourages proper storage and disposal of medications, fostering a safer environment for medication preparation.
Summary of Other Choices:
B: Waiting to document medications until the end of a shift can lead to errors in documentation and potential confusion. Real-time documentation is crucial for accuracy.
C: Removing medications from automatic dispensing systems before pharmacist review bypasses a critical safety check, increasing the risk of errors.
D: Preparing medications for multiple clients simultaneously can lead to mix-ups and errors, as it increases the chances of confusion and incorrect dosing.