Nokea
The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action?
- A. Notify public health services
- B. Dim the lights in the assigned room
- C. Obtain blood cultures
- D. Explore the client's feelings regarding the diagnosis
Correct Answer: C
Rationale: Obtaining blood cultures (C) is the priority action for suspected bacterial meningitis to confirm the diagnosis and guide antibiotic therapy. While droplet precautions (not listed) are also critical to prevent spread, cultures are the most urgent among the options. Notifying public health (A) is secondary, dimming lights (B) addresses comfort, and exploring feelings (D) is not a priority in an acute infection.
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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 is caring for a client who reports that another nurse hit them. The nurse should take which action?
- A. Inquire with the nurse if this incident occurred
- B. Assess the client for any prior episodes of abuse
- C. Determine if the client has any cognitive impairments
- D. Report the client's concern to the nursing supervisor
Correct Answer: D
Rationale: Reporting the allegation to the nursing supervisor (D) is the priority to ensure proper investigation and client safety, per facility policy. Inquiring directly (A), assessing prior abuse (B), or checking cognition (C) risks bias or delays formal action.
The nurse manager has observed a staff nurse return to work late multiple times following the lunch break. The nurse manager should take which initial action?
- A. Continue to observe the nurse's behavior
- B. Reprimand the nurse with written documentation
- C. Ask the nurse to check in before and after taking their lunch break
- D. Discuss with the nurse the consequences of being late
Correct Answer: C
Rationale: Asking the nurse to check in (C) is a proactive initial step to address tardiness while maintaining professionalism and gathering data. Continued observation (A) delays action, reprimand (B) is premature, and discussing consequences (D) escalates without initial intervention.
The nurse in a clinic is triaging clients. Which of the following clients should the nurse see first?
- A. A 17-year-old complaining of abdominal cramping with moderate bloody vaginal discharge
- B. A 25-year-old primigravida reporting blurred vision.
- C. A 50-year-old menopausal client expelling dark red blood clots.
- D. A 70-year-old client who states her uterus is going to 'fall out.'
Correct Answer: B
Rationale: Blurred vision in a 25-year-old primigravida (B) suggests preeclampsia, a life-threatening emergency requiring immediate assessment. Abdominal cramping with bleeding (A), menopausal clotting (C), and uterine prolapse (D) are less urgent, though they require follow-up.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are working together in a psychiatric ward. Which of the following clients can the RN assign to the LPN/VN? A client
- A. taking amitriptyline who is currently grinding their jaw and grimacing
- B. with dementia who is currently confused and disoriented
- C. with bipolar disorder with a lithium level of 2.0 mEq/L [0.6-1.2 mEq/L]
- D. with a history of chronic alcoholism currently experiencing delirium tremens
Correct Answer: B
Rationale: A client with dementia who is confused (B) is stable and suitable for LPN care, focusing on safety and routine tasks. Jaw grinding on amitriptyline (A), toxic lithium level (C), and delirium tremens (D) require RN assessment due to potential toxicity or instability.