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The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing frequent contractions. The nurse observes a presenting part of the fetus during the exam. Which priority action should the nurse take?
- A. Assess the client's previous obstetric history
- B. Prepare for the delivery of the newborn
- C. Transport the client to the labor and delivery unit
- D. Time the frequency and duration of contractions
Correct Answer: B
Rationale: A visible presenting part (B) indicates imminent delivery, requiring immediate preparation for newborn delivery in the ED. Assessing history (A), transporting to labor and delivery (C), or timing contractions (D) delays critical action for an emergency birth.
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The emergency department (ED) nurse is triaging clients in the ED. It would be appropriate for the nurse to triage which client as nonurgent? Select all that apply.
- A. with a localized abscess on the right leg.
- B. reporting that they have chest pressure.
- C. with nausea, vomiting, and painful urination.
- D. requesting a refill of their prescribed antidepressant.
- E. with a single laceration to the left hand.
Correct Answer: A, D, E
Rationale: Nonurgent conditions include a localized abscess (A), antidepressant refill (D), and a single laceration (E), as they are stable and do not require immediate intervention. Chest pressure (B) suggests a cardiac emergency, and nausea, vomiting, and painful urination (C) indicate a possible urinary tract infection, both requiring urgent attention.
The nurse in the emergency department (ED) is caring for an unconscious client who sustained a head injury following a motor vehicle crash. The health care provider (HCP) has ordered an emergency surgery. Which action should the nurse take regarding informed consent?
- A. obtain a court order for the surgical procedure in place of an informed consent
- B. search the client's belongings for any identification
- C. transport the client to the operating room for surgery immediately
- D. call the police to report the incident, identify the client, and locate the family
Correct Answer: C
Rationale: For an unconscious client requiring emergency surgery, implied consent applies, allowing immediate transport to the operating room (C) to save life or prevent harm. Court orders (A), searching belongings (B), or calling police (D) delay critical care and are not required for emergency consent.
The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply.
- A. pulmonary tuberculosis with multiple prescriptions.
- B. ischemic stroke who has left-sided hemiplegia.
- C. hyperthyroidism and is scheduled for a thyroidectomy.
- D. stage one Alzheimer’s disease who lives with family.
- E. fractured tibia and fibula and is homeless.
- F. end-stage-renal disease who refuses dialysis.
Correct Answer: A, B, E, F
Rationale: TB with multiple drugs (A), stroke with hemiplegia (B), homeless with fractures (E), and dialysis refusal (F) require interdisciplinary coordination due to complex medical, social, or ethical needs. Thyroidectomy (C) and early Alzheimer’s (D) are less complex for conferencing.
The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
- A. has a closed-chest drainage system and has redness at the insertion site.
- B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour.
- C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.
Correct Answer: D
Rationale: Hypotension (100/58 mm Hg) in ischemic stroke (D) suggests hemodynamic instability, risking cerebral perfusion and requiring immediate follow-up. Redness at chest tube site (A), bloody stools in ulcerative colitis (B), and mild headache in concussion (C) are concerning but less immediately life-threatening.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP? Select all that apply.
- A. Transport a client with an ankle fracture to radiology.
- B. Calculate and record a client's oral intake for the shift.
- C. Ambulate a client who is eight hours post-laparoscopic surgery.
- D. Assist a client with multiple sclerosis in performing oral care.
- E. Obtain a urine culture and sensitivity sample from an indwelling urethral catheter.
Correct Answer: A, C, D
Rationale: UAPs can transport stable clients (A), ambulate post-surgical clients (C), and assist with oral care (D). Calculating intake (B) requires clinical judgment, and obtaining a urine culture (E) involves sterile technique, both RN/LPN tasks.