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The medical-surgical nurse is assigned to the intensive care unit (ICU). The nurse accepts the hand-off reports and indicates they are not qualified to provide the necessary care. It would be appropriate for the medical-surgical nurse to take which action?
- A. Refuse to provide any client care
- B. Document the concern in the client's medical record
- C. Notify the primary healthcare provider (PHCP)
- D. Report the concerns to the nursing supervisor
Correct Answer: D
Rationale: Reporting concerns to the nursing supervisor (D) ensures safe staffing and reassignment, protecting clients and the nurse. Refusing care (A) is unprofessional, documenting in records (B) is inappropriate, and notifying the provider (C) is not the nurse’s role.
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The registered nurse (RN) observes licensed practical/vocational nurses (LPN/VN) care for assigned clients. Which of the following actions by the LPN would require the RN to intervene? Select all that apply.
- A. Irrigates an indwelling catheter with warm tap water.
- B. Administers glargine insulin for a client with nothing by mouth (NPO) status.
- C. Obtains a 12-lead electrocardiogram for a client with hyperkalemia.
- D. Clamps a chest tube while the client ambulates.
- E. Repositions a client who requires log rolling by using a gait belt.
Correct Answer: A, B, D, E
Rationale: Irrigating with tap water (A) risks infection, insulin for NPO client (B) risks hypoglycemia without RN assessment, clamping a chest tube (D) risks pneumothorax, and using a gait belt for log rolling (E) is incorrect technique. ECG (C) is within LPN scope.
The nurse working in the emergency department is caring for a client with carbon monoxide poisoning. Which of the following would be the priority action to treat this condition?
- A. Initiate continuous pulse oximetry monitoring
- B. Administer high-flow oxygen
- C. Insert a peripheral vascular access device
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: B
Rationale: High-flow oxygen (B) is the priority for carbon monoxide poisoning to displace CO from hemoglobin, per ACLS guidelines. Pulse oximetry (A) is unreliable in CO poisoning, IV access (C) and ECG (D) are secondary to oxygenation.
A client has refused a prescribed injection of subcutaneous heparin. Which initial action should the nurse take?
- A. Document the refusal
- B. Notify the primary healthcare provider (PHCP)
- C. Review the client's most recent platelet count
- D. Inquire with the client about the refusal
Correct Answer: D
Rationale: Inquiring about the refusal (D) allows the nurse to understand the client’s concerns, provide education, and address barriers, promoting informed decision-making. Documenting (A) and notifying the provider (B) are secondary steps, and reviewing platelet count (C) is irrelevant without addressing the refusal first.
The nurse has completed medication administration to assigned clients. The nurse should initially follow up on the client who received prescribed
- A. mirtazapine and reports sleepiness.
- B. citalopram and reports nausea.
- C. fluphenazine and reports fever.
- D. clonidine and reports dizziness while rolling over in bed.
Correct Answer: C
Rationale: Fever after fluphenazine (C) suggests neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Sleepiness with mirtazapine (A), nausea with citalopram (B), and dizziness with clonidine (D) are expected side effects and less urgent.
The nurse is providing discharge instructions to a client who speaks a language different from the nurse's. The client's family members are present, and they speak English. Which action by the nurse is the most appropriate to ensure effective communication during the discharge process?
- A. Use a smartphone translation app to convey the instructions to the client.
- B. Provide written material in the client's language and provide oral instructions in English.
- C. Request an interpreter from the hospital's language services to assist with the discharge instructions.
- D. Summarize the instructions in basic English and have the family members relay the information to the client.
Correct Answer: C
Rationale: Using a professional interpreter (C) ensures accurate communication, adhering to legal and ethical standards for discharge teaching. Smartphone apps (A) are unreliable, written material with English oral instructions (B) is ineffective, and relying on family (D) risks misinterpretation.