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The emergency department (ED) is caring for a client with a pulse (P) of 42, blood pressure (BP) of 90/60 mm Hg, and reports dizziness. Which of the following actions is the priority?
- A. Obtain an order for a chest radiograph (x-ray)
- B. Review the client's current medications
- C. Perform a focused neurological assessment
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: D
Rationale: A pulse of 42 with hypotension and dizziness (D) suggests symptomatic bradycardia, requiring an immediate ECG to identify arrhythmias, per ACLS guidelines. Chest x-ray (A), medication review (B), and neurological assessment (C) are secondary to cardiac evaluation.
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The charge nurse of a medical-surgical unit is informed that the nursing unit is short-staffed. Which task should the charge nurse delay in order to meet all client needs?
- A. Medication administration
- B. Daily baths
- C. Vital sign collection
- D. Hourly safety rounds
Correct Answer: B
Rationale: Daily baths (B) can be delayed as they are non-essential for immediate client safety. Medication administration (A), vital signs (C), and safety rounds (D) are critical for client care and cannot be postponed.
The medical-surgical nurse is preparing for the admission of an older adult following a ground-level fall. The nurse should prioritize teaching the client
- A. how to use the telephone and order meals.
- B. their prescribed medications for the shift.
- C. the prescribed pain management plan.
- D. how to operate the call light.
Correct Answer: D
Rationale: Teaching how to operate the call light (D) is the priority to ensure the client can request assistance, preventing falls and ensuring safety. Telephone use (A), medications (B), and pain management (C) are important but secondary to immediate safety needs.
The nurse is caring for a group of children on the medical-surgical unit. The nurse should initially follow up on the child who
- A. is receiving treatment for Hirschsprung's disease and has a temperature of 101°F (38.3°C).
- B. has an indwelling urinary catheter and reports burning at the insertion site.
- C. has scant blood in their newly established ostomy pouch.
- D. has friends writing words on their fiberglass cast with different colored markers.
Correct Answer: A
Rationale: A fever of 101°F in Hirschsprung’s disease (A) suggests possible enterocolitis, a life-threatening complication requiring immediate follow-up. Catheter burning (B), scant ostomy blood (C), and cast writing (D) are less urgent, as they are expected or non-threatening.
A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
The registered nurse (RN) supervises a licensed practical/vocational nurse (LPN). Which statement by the LPN/VN requires follow-up by the RN?
- A. I bathed the client already this morning'
- B. I passed out letters and packages to the clients this morning.'
- C. The client refused his prescribed valproic acid, so I snuck it into his food.'
- D. I will be joining the clients with their games today in the day room.'
Correct Answer: C
Rationale: Hiding medication in food (C) is unethical, unsafe, and violates client autonomy, requiring immediate RN follow-up. Bathing (A), distributing mail (B), and joining games (D) are within the LPN’s scope and do not require intervention.