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The charge nurse is making assignments in the intensive care unit (ICU) and is making client assignments for a nurse floated from the medical-surgical (med-surg) unit. Which client would be appropriate to assign to the nurse floated from med-surg?
- A. A client with bacteremia who is suspected of developing shock.
- B. A client requiring the titration of intravenous (IV) vasopressors based on hemodynamic monitoring.
- C. A client receiving intravenous (IV) antibiotics and nebulizer treatments for pneumonia.
- D. A client with targeted temperature management three hours after experiencing cardiac arrest.
Correct Answer: C
Rationale: A client receiving IV antibiotics and nebulizers for pneumonia (C) is stable and aligns with med-surg skills, suitable for a float nurse. Bacteremia with shock (A), vasopressor titration (B), and targeted hypothermia (D) require ICU expertise.
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The nurse is caring for a client experiencing an acute episode of vertigo. Which of the following actions would be a priority for the nurse?
- A. instruct the client to avoid sudden, jerky movements.
- B. Request a prescription for an antihistamine.
- C. Raise the upper side rails of the client's bed.
- D. Assess the client for nausea and vomiting.
Correct Answer: C
Rationale: Raising side rails (C) is the priority in acute vertigo to prevent falls due to dizziness, ensuring immediate safety. Avoiding movements (A), antihistamine (B), and nausea assessment (D) are important but secondary to fall prevention.
The nurse in the emergency department is triaging a group of clients. It would be a priority for the nurse to follow up with the child
- A. reporting increased urinary frequency and pain during urination.
- B. diagnosed with leukemia who has petechiae on their torso.
- C. diagnosed with acute epiglottitis two days ago and is drooling.
- D. with otitis media who has a temperature of 101.1°F (38.4°C) and is crying.
Correct Answer: C
Rationale: Drooling in a child with acute epiglottitis (C) suggests airway obstruction, a life-threatening emergency requiring immediate follow-up. Urinary symptoms (A), petechiae in leukemia (B), and otitis media (D) are less urgent, though concerning.
The nurse in the emergency department (ED) is caring for a client and establishes continuous cardiac monitoring. Which initial action should the nurse take based on the electrocardiogram tracing? See the exhibit for additional client information.
- A. Establish vascular access and request a prescription for atropine
- B. Assess the client's blood pressure and level of consciousness
- C. Obtain and review the client's current medications
- D. Document the findings and reassess the client in one hour
Correct Answer: B
Rationale: Sinus bradycardia can be benign or symptomatic. The priority is to determine whether the client is hemodynamically stable by assessing blood pressure (BP) and level of consciousness (LOC). If the client is symptomatic (e.g., hypotension, dizziness, altered mental status), further interventions such as atropine administration may be required.
The charge nurse is orientating a newly hired nurse to the charge nurse role. Which observation by the charge nurse requires follow-up? The newly hired nurse Select all that apply.
- A. requests the unlicensed assistive personnel (UAP) transport a client with respiratory distress to radiology.
- B. asks the licensed practical/vocational nurse (LPN/VN) to witness informed consent for a client scheduled for surgery.
- C. instructs the licensed practical/vocational nurse (LPN/VN) to review orders just written by the physician.
- D. assks the unlicensed assistive personnel (UAP) to transport blood specimens to the lab.
- E. assigns a client immediately postoperative from cardiac catheterization to a licensed practical/vocational nurse (LPN/VN).
Correct Answer: A, B
Rationale: Transporting a client with respiratory distress (A) by a UAP is unsafe, as they require monitoring. An LPN witnessing consent (B) is outside their scope; RNs or providers typically do this. Reviewing orders (C), transporting specimens (D), and assigning a stable post-catheterization client (E) are appropriate.
The registered nurse (RN) is orienting a new RN to the charge nurse role. When delegating tasks, which task delegated to the licensed practical/vocational nurse (LPN/VN) would require follow-up from the charge nurse?
- A. Obtaining an occult stool sample for a client with ulcerative colitis.
- B. Assessing a newly admitted client with chest pain.
- C. Reinforcing teaching to a client newly diagnosed with diabetes mellitus.
- D. Providing pin care for a client with external fixation of the wrist.
Correct Answer: B
Rationale: Assessing a new client with chest pain (B) requires RN-level judgment due to potential life-threatening conditions, necessitating follow-up if delegated to an LPN. Stool sample collection (A), reinforcing teaching (C), and pin care (D) are within LPN scope.