Nokea
A nurse is caring for a client who is admitted to the emergency department with suspected rhabdomyolysis. Which of the following interventions should the nurse anticipate implementing initially for this client?
- A. Administering intravenous fluids
- B. Monitoring the client’s liver enzymes
- C. Administering corticosteroids
- D. Initiating prophylactic antibiotic therapy
Correct Answer: A
Rationale: Intravenous fluids (A) are the initial intervention for rhabdomyolysis to prevent kidney damage by flushing myoglobin and maintaining urine output. Monitoring liver enzymes (B), corticosteroids (C), and antibiotics (D) are not primary interventions for this condition.
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The nurse is demonstrating effective prioritization for assigned clients. Place the actions in the order in which they need to be performed, starting with the highest priority.
- A. Complete an incident report about a client fall that occurred three hours ago.
- B. Perform a sterile dressing change on a client with a sacral wound.
- C. Suction a client's endotracheal tube who is receiving mechanical ventilation.
- D. Administer prescribed antihypertensive medications to a client with hypertension.
- E. Administer a prescribed long-acting bronchodilator via nebulizer for a client with pneumonia.
Correct Answer: C, D, B, E, A
Rationale: 1. Suctioning an endotracheal tube (C) ensures airway patency, a life-saving priority. 2. Administering antihypertensives (D) prevents cardiovascular complications. 3. Sterile dressing change (B) prevents infection but is less urgent. 4. Bronchodilator (E) improves breathing but is long-acting, less time-sensitive. 5. Incident report (A) is administrative and not urgent.
The nurse has received a change-of-shift report for assigned clients. The nurse should initially followup on the client with
- A. cystic fibrosis who is coughing up a large amount of yellow mucus.
- B. cellulitis in the lower extremity reporting pain rated 6/10 on the Numerical Rating Scale.
- C. chronic obstructive pulmonary disease reporting blood-tinged sputum 4 hours after a bronchoscopy.
- D. dumping syndrome reporting blurred vision and disorientation.
Correct Answer: A
Rationale: Yellow mucus in cystic fibrosis (A) suggests a possible infection or exacerbation, requiring immediate assessment to prevent respiratory compromise. Cellulitis pain (B), post-bronchoscopy sputum (C), and dumping syndrome symptoms (D) are less urgent, though blurred vision in (D) warrants monitoring.
The nurse has become aware of the following client situations. The nurse should first follow up with the client who
- A. has an irregular pulse and is receiving treatment for atrial fibrillation.
- B. has influenza and had an increase in temperature to 102°F (39°C).
- C. is receiving nebulizer treatments for asthma that suddenly stops wheezing.
- D. has an indwelling urinary catheter and reports burning at the insertion site.
Correct Answer: C
Rationale: Sudden cessation of wheezing in asthma (C) may indicate severe airway obstruction, a life-threatening emergency. Irregular pulse (A), fever with influenza (B), and catheter burning (D) are concerning but less immediately critical.
The nurse manager reviews the results of a staff satisfaction survey. The feedback requests better engagement from the manager and staff involvement in unit-based decisions. Based on this feedback, the nurse manager plans to adjust their management style to
- A. democratic.
- B. transactional.
- C. laissez-faire.
- D. autocratic.
Correct Answer: A
Rationale: A democratic management style (A) involves staff in decision-making, addressing the feedback for better engagement and involvement. Transactional (B), laissez-faire (C), and autocratic (D) styles do not promote collaborative decision-making.
The nurse manager is conducting a staff in-service and announces that the staff nurses may decide when to take meal breaks, and the assignment for new admissions may be decided upon themselves. The nurse manager is demonstrating
- A. authoritative leadership style.
- B. democratic leadership style.
- C. participative leadership style.
- D. laissez-faire leadership style.
Correct Answer: D
Rationale: Allowing staff to decide meal breaks and assignments (D) reflects a laissez-faire leadership style, characterized by minimal direction and high autonomy. Authoritative (A) is directive, democratic/participative (B, C) involve shared decision-making but with more guidance.