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The emergency department (ED) nurse is assigned clients with assigned clients. Place the actions in the order of priority, starting with the highest priority.
- A. Dress a wound for a client discharged with multiple lacerations to the right arm.
- B. Insert a peripheral vascular access device for a client with mild dehydration and infuse prescribed fluids.
- C. Assess a client’s blood pressure who is receiving an infusion of dopamine.
- D. Witness informed consent for a client scheduled for surgery in six hours.
- E. Administer prescribed magnesium sulfate infusion for a client with status asthmaticus.
Correct Answer: C, E, B, D, A
Rationale: Assessing BP on dopamine (C) ensures hemodynamic stability, followed by magnesium for status asthmaticus (E) to control life-threatening bronchospasm. IV access for dehydration (B), informed consent (D), and wound dressing (A) are less urgent, as they address stable or non-emergent needs.
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The nurse is planning care for a client being admitted with cardiac dysrhythmias. When planning care for this client, the nurse should prioritize
- A. auscultating heart tones.
- B. establishing continuous electrocardiogram (ECG) monitoring.
- C. obtaining vital signs.
- D. establishing a secondary peripheral vascular access device.
Correct Answer: B
Rationale: Continuous ECG monitoring (B) is the priority for cardiac dysrhythmias to detect and manage life-threatening arrhythmias in real-time. Auscultating heart tones (A), vital signs (C), and IV access (D) are important but secondary to monitoring.
The nurse offers to stay late to assist the next shift because they are short-staffed. Which ethical principle is the nurse demonstrating?
- A. Non-maleficence
- B. Paternalism
- C. C. Beneficence
- D. D. Veracity
Correct Answer: C
Rationale: Staying late to assist (C) demonstrates beneficence by acting to benefit staff and clients through additional support. Non-maleficence (A), paternalism (B), and veracity (D) do not apply to this act of goodwill.
The emergency department (ED) nurse is caring for a client who just arrived with a major thermal burn to 22.5% of the total body surface area (TBSA). Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Establish a large bore peripheral vascular access device to unburned skin.
- B. Insert an indwelling urinary catheter to maintain urinary output 0.5 mL/kg/hr.
- C. Administer tetanus prophylaxis as prescribed.
- D. Administer supplemental oxygen if indicated and cover burns with sterile gauze.
- E. Assess the client's airway, breathing, and circulation and obtain vital signs.
- F. Administer prescribed isotonic fluids intravenously to maintain fluid balance.
Correct Answer: E, D, A, F, B, C
Rationale: Initial assessment of airway, breathing, circulation (E) ensures stability, followed by oxygen and burn coverage (D) for hypoxia prevention. IV access (A) and fluids (F) address shock, catheter insertion (B) monitors output, and tetanus prophylaxis (C) is last, as it’s preventive.
The nurse has learned during nursing school to maintain honesty and openness with all clients, even when conveying potentially distressing information. This approach aligns with the ethical principle of
- A. beneficence.
- B. veracity.
- C. nonmaleficence.
- D. fidelity.
Correct Answer: B
Rationale: Honesty and openness (B) align with veracity, the ethical principle of truth-telling. Beneficence (A) promotes well-being, nonmaleficence (C) avoids harm, and fidelity (D) keeps promises, but veracity is most relevant here.
A charge nurse is preparing client assignments for the shift. Which client is most appropriate to assign to a licensed practical/vocational nurse (LPN/VN)?
- A. A client with a chest tube requiring frequent oral suctioning.
- B. A client receiving continuous IV heparin for a pulmonary embolism (PE).
- C. A client 24 hours post-abdominal surgery requiring daily wound care.
- D. A client with new-onset seizures awaiting diagnostic tests.
Correct Answer: C
Rationale: A client 24 hours post-abdominal surgery needing wound care (C) is stable and within the LPN scope. Chest tube suctioning (A) and heparin infusion (B) require RN monitoring for complications. New-onset seizures (D) require RN assessment due to instability.