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The emergency department (ED) nurse cares for a client who presents with irritability, nuchal rigidity, and a fever. Which of the following actions should the nurse take first?
- A. Administer prescribed ibuprofen.
- B. Place the client on droplet precautions.
- C. Notify the public health department.
- D. Obtain prescribed blood cultures.
Correct Answer: B
Rationale: Placing the client on droplet precautions (B) is the first action for suspected meningitis (irritability, nuchal rigidity, fever) to prevent spread of infection. Administering ibuprofen (A), notifying public health (C), and obtaining blood cultures (D) are important but secondary to infection control.
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The nurse is preparing medications for the shift. Which of the following clients should the nurse prioritize for immediate medication administration?
- A. Digoxin to a client with atrial fibrillation
- B. Furosemide to a client with congestive heart failure
- C. Magnesium sulfate to a client with Torsades de pointes
- D. Labetalol to a client with a blood pressure of 160/100 mmHg
Correct Answer: C
Rationale: Magnesium sulfate for Torsades de pointes (C) is the priority to stabilize life-threatening ventricular arrhythmias, per ACLS guidelines. Digoxin (A), furosemide (B), and labetalol (D) address less acute conditions.
The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
The following scenario applies to the next 1 items
The charge nurse in the medical-surgical unit is preparing the assignment for the next shift.
• Client One
• 63-year-old male admitted three days ago for community-acquired pneumonia.
• Intravenous (IV) antibiotics stopped and were switched to oral. Plan is for discharge in one day. Family is at the bedside.
• Current medications: azithromycin, levofloxacin, warfarin, atorvastatin, acetaminophen, and albuterol via nebulizer.
• Medical history: mitral valve replacement, venous thromboembolism, and hyperlipidemia.
• Vital signs: T 101° F (39.7° C), P 72, RR 18, BP 130/86, pulse oximetry reading 95% on room air.
• Client Two
• 55-year-old female admitted two days ago with aplastic anemia.
• Received two units of packed red blood cells yesterday.
• Client is scheduled to receive two units of platelets. She developed epistaxis and vaginal bleeding in the last hour.
• Current medications: multivitamin and lisinopril.
• Medical history: aplastic anemia and hypertension.
• Vital signs: T 98.6° F (37° C), P 88, RR 15, BP 111/76, pulse oximetry reading 96% on room air.
• Client Three
• 23-year-old male admitted four days ago with chest trauma caused by a stab wound.
• Transferred to the medical-surgical unit yesterday. Chest tube was discontinued yesterday.
• Client is to ambulate every four hours (while awake). Has constipation and needs an enema.
• Current medications: oxycodone-acetaminophen, docusate, and regular insulin sliding scale.
• Medical history: diabetes mellitus (type one).
• Vital signs: T 98° F (36.4° C), P 80, RR 16, BP 119/86, pulse oximetry reading 96% on room air.
• Client Four
• 52-year-old female admitted two hours ago following total abdominal hysterectomy.
• Occasional nausea. Hypoactive bowel sounds in all quadrants. Has an indwelling urinary catheter connected to drainage bag.
• Current medications: hydrocodone-acetaminophen, docusate, and ondansetron.
• Medical history: cervical cancer.
• Vital signs: T 98° F (36.4° C), P 70, RR 16, BP 125/88, pulse oximetry reading 95% on room air
• Client Five
• 45-year-old male admitted four hours ago with new onset atrial fibrillation.
• Irregular pulse. Had two episodes of syncope in the emergency department.
• Current medications: continuous infusion of diltiazem.
• Medical history: hypertension and congestive heart failure.
• Vital signs: T 98° F (36.4° C), P 101, RR 19, BP 137/90, pulse oximetry reading 96% on room air
• Client Six
• 77-year-old male admitted one day ago with cystitis.
• Receives medications and feedings through percutaneous endoscopic gastrostomy (PEG). Requires daily dressing changes for sacral pressure ulcer.
• Current medications: citalopram, esomeprazole, atenolol, ciprofloxacin.
• Medical history: hypertension, anxiety, acid reflux.
• Vital signs: T 98.2° F (36.8° C), P 82, RR 15, BP 133/88, pulse oximetry reading 95% on room air
• Client Seven
• 72-year-old female admitted two days ago with cystitis and improving altered mental status.
• Receiving intermittent intravenous piggyback antibiotics.
• Current medications: rivaroxaban, diltiazem, and captopril.
• Medical history: atrial fibrillation and hypertension.
• Vital signs: T 98.9° F (37.2° C), P 67, RR 16, BP 143/85, pulse oximetry reading 96% on room air
The charge nurse is determining which client should be assigned to the licensed practical/vocational nurse (LPN/VN) or registered nurse (RN).Click to specify if the client should be assigned to the LPN/VN or RN.
- A. Client One
- B. Client Two
- C. Client Three
- D. Client Four
- E. Client Five
- F. Client Six
- G. Client Seven
Correct Answer:
Rationale: Client One
This client is stable, with IV antibiotics discontinued and switched to oral. The LPN can manage routine medication administration, monitor for any signs of infection recurrence, and provide discharge education under the supervision of an RN.
Client Three
The client is stable and primarily requires routine care, such as scheduled ambulation and assistance with bowel management (enema administration). The LPN is qualified to administer medications and monitor for any changes in respiratory status following chest trauma.
Client Six
This client is stable and requires PEG tube feedings, medication administration, and daily dressing changes for a sacral pressure ulcer. These tasks fall within the LPN’s scope of practice, as long as the RN remains available for more complex assessments if needed.
Client Seven
The client is showing improvement, is hemodynamically stable, and requires intermittent IV piggyback antibiotics. LPNs are trained to administer IV piggyback medications and monitor for adverse effects. Routine vital sign monitoring and medication administration are appropriate for LPN delegation.
Clients that should be assigned to the RN
Client Two
This client presents an increased risk of hemodynamic instability due to new-onset bleeding (epistaxis and vaginal bleeding), requiring close assessment and intervention. The RN is needed to evaluate the severity of bleeding, administer platelet transfusions, and monitor for transfusion reactions or worsening anemia.
Client Four
Postoperative clients are at risk for complications such as hemorrhage, infection, and ileus. The RN is required to perform a comprehensive assessment, evaluate bowel function, manage nausea, and ensure the catheter remains patent without signs of infection.
Client Five
This client is on continuous IV diltiazem, which requires ongoing cardiac monitoring and dosage adjustments based on response. The client’s history of syncope raises concerns for hemodynamic instability, which necessitates RN oversight for timely intervention if deterioration occurs.
The nurse is planning a staff education program about conflict resolution strategies. It is appropriate for the nurse to identify that compromising in a conflict may result in
- A. incomplete satisfaction of both parties’ concerns.
- B. appeasing an individual by self-sacrificing.
- C. suppression of thoughts and feelings.
- D. satisfaction of an individual’s interest regardless of the impact on others.
Correct Answer: A
Rationale: Compromising in conflict (A) often results in incomplete satisfaction for both parties, as each gives up something to reach agreement. Appeasing (B) involves self-sacrifice, suppression (C) avoids conflict, and individual satisfaction (D) reflects winning, not compromising.
The nurse is caring for a client with suspected sepsis. After reviewing the client's vital signs, which prescription by the primary healthcare provider (PHCP) should the nurse administer first? See the images below.
- A. Ceftriaxone
- B. Doxycycline
- C. Acetaminophen
- D. 0.9% sodium chloride (normal saline) bolus
Correct Answer: D
Rationale: This client is in shock. A blood pressure of 90/60 mm Hg is clinical hypotension combined with the client's tachycardia. The client needs immediate fluid volume resuscitation to prevent further clinical decline. Sepsis is a medical emergency, and the client will require prompt antibiotics. Still, it will not prioritize treating the client's hypovolemia which is the immediate concern illustrated by the low blood pressure.