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An RN delegates patient assignments to an LPN and nursing assistant. Later, the RN overhears a nursing assistant arguing with a patient regarding a late breakfast tray. The nursing assistant begins to raise his voice as the disagreement continues. The best action from the RN is
- A. call the nursing assistant out of the room and speak with him about the incident.
- B. apologize to the patient and assign another nursing assistant to that room.
- C. report the nursing assistant to the nursing manager for poor patient care.
- D. write an incident report and give a copy to the nursing assistant and nurse manager.
Correct Answer: A
Rationale: Addressing the nursing assistant privately de-escalates the situation, provides coaching, and maintains professionalism without immediate escalation.
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The nurse is caring for an elderly client who presents to the ED with poor appetite, confusion, and weakness. Lab work is ordered for the client. The nurse should immediately notify the health care provider for which lab result?
- A. chloride 99 mEq/L
- B. calcium 9.4 mg/dL
- C. sodium 118 mEq/L
- D. potassium 4.2 mEq/L
Correct Answer: C
Rationale: Severe hyponatremia (sodium 118 mEq/L) can cause confusion and weakness and requires immediate provider notification. Other values are within normal ranges.
The nurse is caring for a client receiving supplemental oxygen. The effectiveness of the oxygen therapy is best determined by:
- A. The rate of respirations
- B. The absence of cyanosis
- C. Arterial blood gases
- D. The level of consciousness
Correct Answer: C
Rationale: Arterial blood gases provide a direct measure of oxygenation and are the most accurate way to evaluate the effectiveness of oxygen therapy.
A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?
- A. Before the first dose
- B. 30 minutes before the fourth dose
- C. 30 minutes after the first dose
- D. 30 minutes before the first dose
Correct Answer: B
Rationale: Trough levels measure the lowest drug concentration and are drawn just before a dose after steady-state, typically around the fourth dose for Gentamicin.
The nurse is teaching the mother of a child with cystic fibrosis how to do chest percussion. The nurse should tell the mother to:
- A. Use the heel of her hand during percussion
- B. Change the child's position every 20 minutes during percussion sessions
- C. Do percussion after the child eats and at bedtime
- D. Use cupped hands during percussion
Correct Answer: D
Rationale: Cupped hands during chest percussion create a vibration that helps loosen mucus in cystic fibrosis without causing injury.
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT the nurse should:
- A. Apply a tourniquet to the client's arm.
- B. Administer an anticonvulsant medication.
- C. Ask the client if he is allergic to shell fish.
- D. Apply a blood pressure cuff to the arm.
Correct Answer: D
Rationale: Applying a blood pressure cuff allows monitoring of vital signs during ECT, which is a standard safety measure.