Nokea
A nurse is providing discharge teaching to the parent of a toddler who has a new diagnosis of asthma. The parent states she is unable to afford the nebulizer prescribed for the child. Which of the following referrals should the nurse recommend?
- A. Pharmacist
- B. Respiratory therapist
- C. Social worker
- D. Child protective services
Correct Answer: C
Rationale: A social worker can connect the family with financial resources to obtain the nebulizer, addressing the affordability issue.
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A nurse is teaching a class of newly licensed nurses about evidence-based practice. The nurse should include which of the following as the first step in evidence-based practice?
- A. Develop a clinical question.
- B. Collect evidence from a variety of sources.
- C. Apply research to client care practice.
- D. Critically assess the evidence.
Correct Answer: A
Rationale: The correct answer is A: Develop a clinical question. This is the first step in evidence-based practice as it helps focus the search for evidence. By formulating a clear and specific question, nurses can identify relevant research studies to inform their practice. Collecting evidence (B) comes after formulating the question. Applying research to practice (C) and critically assessing evidence (D) are important steps but occur later in the process.
A nurse on a medical-surgical unit is caring for four clients. The nurse should recognize that which of the following clients is the highest priority?
- A. A client who has peripheral vascular disease and has an absent pedal pulse in the right foot
- B. A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38° C (101° F)
- C. A client who is postoperative following a laminectomy 12 hr ago and is unable to void
- D. A client who is newly diagnosed with pancreatic cancer and is scheduled to begin IV chemotherapy
Correct Answer: A
Rationale: An absent pedal pulse indicates a critical circulatory issue, potentially limb-threatening, requiring immediate attention over other less urgent conditions.
A nurse is providing an in-service about actions to take during a fire on the unit. Which of the following instructions should the nurse include?
- A. Place dry towels at the base of doors.
- B. Move client care equipment into the hallway.
- C. Close the windows in client rooms.
- D. Use the fire extinguisher by aiming at the top of the flames.
Correct Answer: C
Rationale: The correct answer is C: Close the windows in client rooms. Closing windows can help prevent the spread of fire by limiting oxygen supply. This action can help contain the fire within the unit and prevent it from escalating. Placing dry towels at door bases (choice A) can be dangerous as they can catch fire. Moving client care equipment into the hallway (choice B) can obstruct evacuation routes. Using a fire extinguisher by aiming at the top of flames (choice D) is incorrect as the base of the fire should be targeted to extinguish it effectively.
A charge nurse notices that staff nurses are having difficulty using new IV infusion pumps for medication administration. Which of the following is the priority action by the charge nurse?
- A. Assess the staff nurses' knowledge deficit.
- B. Demonstrate use of the pump during medication administration.
- C. Plan an in-service education program on the unit.
- D. Pair an inexperienced nurse with an experienced nurse.
Correct Answer: A
Rationale: The correct answer is A: Assess the staff nurses' knowledge deficit. This is the priority action because it helps identify the root cause of the difficulty with the new IV infusion pumps. By assessing the staff nurses' knowledge deficit, the charge nurse can determine if additional training, education, or support is needed. This step is crucial in addressing the problem effectively and ensuring safe medication administration.
Other choices:
B: Demonstrating the use of the pump during medication administration may be helpful but should come after assessing the knowledge deficit.
C: Planning an in-service education program is important but should be based on the assessment of the staff nurses' knowledge deficit.
D: Pairing an inexperienced nurse with an experienced nurse may be beneficial but does not directly address the underlying issue of knowledge deficit.
A nurse in an emergency department is triaging four clients following a mass casualty event. To which of the following clients should the nurse assign a red tag?
- A. A client who experienced a brief loss of consciousness
- B. A client who has major burns covering 70% of their body
- C. A client who has fixed pupils
- D. A client who has a compromised airway
Correct Answer: D
Rationale: The correct answer is D: A client who has a compromised airway. Assigning a red tag indicates the client needs immediate attention and has life-threatening injuries. A compromised airway can lead to rapid deterioration and death if not addressed promptly, making it the priority. Brief loss of consciousness (A) may not indicate immediate danger. Major burns (B) require urgent care but may not lead to imminent death like an obstructed airway. Fixed pupils (C) suggest neurological issues but may not be immediately life-threatening. In this scenario, ensuring a patent airway is crucial for the client's survival, warranting a red tag assignment.