Nokea
The ED nurse is attending orientation for nurses new to working in the ED. As part of the training, the ED nurse would expect to report which conditions to the proper authorities? Select all that apply.
- A. West Nile virus
- B. herpes simplex
- C. gunshot wounds
- D. elder abuse or neglect
- E. bites from an unknown dog
Correct Answer: A,C,D,E
Rationale: West Nile virus, gunshot wounds, elder abuse, and unknown dog bites are reportable due to public health or legal mandates.
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The nurse is charting on his client, who had an open appendectomy the previous day. Which are appropriate nursing documentation entries? Select all that apply.
- A. The client appeared anxious when several family members came to visit.
- B. The client appeared angry when the health care provider changed her medications.
- C. The client tolerated 80% of the lunch tray with no complaints of nausea or stomach cramping.
- D. The client ambulated 200 feet in the hall with a cane. No dyspnea or syncope noticed. Tolerated well.
Correct Answer: C,D
Rationale: Objective entries about meal tolerance and ambulation are appropriate. Subjective terms like 'appeared anxious' or 'appeared angry' lack measurable data.
The nurse is preparing to interpret an electrocardiogram rhythm strip. Identify the order for interpreting the strip. Use all the options.
- A. measure the P-R interval
- B. determine the heart rate and rhythm
- C. analyze the P waves
- D. measure the QRS duration
Correct Answer: B,C,A,D
Rationale: The correct order is: determine heart rate and rhythm, analyze P waves, measure P-R interval, then QRS duration for systematic ECG interpretation.
The nurse is caring for clients on a medical-surgical floor. Which tasks related to pain management can be delegated to unlicensed assistive personnel (UAP)? Select all that apply.
- A. assessing the pain level on a scale of 1-10
- B. reminding clients to report pain immediately
- C. reporting facial grimacing in unresponsive clients
- D. asking clients directly, 'Are you having any pain right now?'
- E. giving acetaminophen (Tylenol) after the nurse obtains the medication but is interrupted to attend a code blue before she administers it
Correct Answer: B,C,D
Rationale: UAPs can remind clients to report pain (B), report objective signs like grimacing (C), and ask about pain presence (D), as these tasks do not require clinical judgment. Assessing pain levels (A) requires nursing judgment, and administering medications (E) is outside the UAP's scope.
Which diagnostic tool is most commonly used to determine the location of the myocardial damage?
- A. electrocardiogram (ECG)
- B. echocardiogram
- C. cardiac enzymes
- D. cardiac catheterization
Correct Answer: A
Rationale: An ECG is the primary tool to identify the location of myocardial damage by showing characteristic waveform changes. Echocardiograms assess heart function, enzymes indicate damage but not location, and catheterization is invasive and less common initially.
The nurse is admitting a new client complaining of severe abdominal pain. When asked about valuables, the client says he has $1,500 cash in his wallet. He is from out of state and does not have anyone who can take his wallet into safekeeping for him. Which statement by the nurse best addresses this situation?
- A. I can keep it locked up in the charge nurse's office for you.
- B. It should be fine. Just hide it in a drawer when you go down for a CT scan.
- C. I can call security to bring a form to fill out, and they will lock it up for you.
- D. You will have to call someone to come get it. We can't let you keep it in your room.
Correct Answer: C
Rationale: Security handling valuables follows hospital policy, ensuring safety and documentation.