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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.
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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 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 registered nurse (RN) assigns client care to a licensed practical/vocational nurse (LPN/VN). Which of the following clients should the RN assign to the LPN? Select all that apply. A client
- A. requiring an assessment of their current prescribed medications.
- B. needing a nasogastric tube (NGT) for enteral feedings.
- C. with an insulin pump and is unsure of how to load the insulin.
- D. with unstable blood pressure following adrenalectomy.
- E. requiring airborne isolation and bronchodilators via an inhaler.
Correct Answer: B, E
Rationale: Administering enteral feedings via NGT (B) and bronchodilators via inhaler (E) are within the LPN’s scope for stable clients. Medication assessment (A), insulin pump teaching (C), and unstable BP post-adrenalectomy (D) require RN-level judgment due to complexity or instability.
The nurse is caring for a group of preoperative clients. Which client situation requires follow-up? A client, Select all that apply.
- A. stating that they took their prescribed carbamazepine with a sip of water.
- B. receiving dextrose 5% in water (D5W) and has a blood glucose of 266 mg/dL (14.77 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L].
- C. reporting that they shaved their abdomen for their scheduled appendectomy.
- D. reporting difficulty with their last surgery, stating they got 'a really high fever'.
- E. reporting burning upon urination and increased urinary frequency.
Correct Answer: B, C, D, E
Rationale: High blood glucose (B) risks surgical complications, shaving abdomen (C) increases infection risk, past surgical fever (D) suggests complications, and urinary symptoms (E) indicate possible UTI, all needing follow-up. Carbamazepine with water (A) is typically acceptable pre-op.
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.