Nokea
The nurse administers intravenous levofloxacin instead of the prescribed azithromycin. Which of the following actions should the nurse take first?
- A. Stop the infusion
- B. Complete an incident report
- C. Obtain vital signs
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: A
Rationale: Stopping the infusion (A) is the first action to prevent further harm from the medication error. Notifying the provider (D), obtaining vital signs (C), and completing an incident report (B) follow after halting the incorrect medication.
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The nurse reviews the nursing process with a group of students. Which of the following would demonstrate implementation? Select all that apply.
- A. Performing a sterile dressing change
- B. Interviewing the client about their social determinants
- C. Inputs risk for impaired skin integrity into the care plan
- D. Establishing a peripheral vascular access device
- E. Determining if the prescribed pain medication was effective
Correct Answer: A, D
Rationale: Performing a dressing change (A) and establishing IV access (D) are implementation actions, executing the care plan. Interviewing (B) is assessment, inputting risks (C) is planning, and determining medication effectiveness (E) is evaluation.
A hospital is initiating its emergency disaster plan following a mass casualty incident. Which client should the nurse recommend for discharge in preparation for the incoming clients?
- A. A client with type 1 diabetes admitted for new-onset diabetic ketoacidosis and is receiving intravenous insulin
- B. A client with atrial fibrillation admitted 2 days ago, now on oral anticoagulants and in normal sinus rhythm
- C. A client admitted with community-acquired pneumonia requiring oxygen at 3 L/min via nasal cannula
- D. A client admitted with a tibial fracture 6 hours ago, who is post-operative with a cast and stable vital signs
Correct Answer: B
Rationale: The client with atrial fibrillation, now stable on oral anticoagulants (B), is the most suitable for discharge to free beds. Diabetic ketoacidosis (A), pneumonia with oxygen (C), and recent post-operative fracture (D) require ongoing hospital care.
The registered nurse (RN) is working with a licensed practical/vocational nurse (LPN/VN). Which client assignment should the RN delegate to the LPN? A client
- A. immediately post-operative following a thyroidectomy.
- B. with a paralytic ileus requiring the management of a nasogastric tube.
- C. receiving intravenous magnesium sulfate for status asthmaticus.
- D. with a hypertensive crisis requiring initiation of intravenous nicardipine.
Correct Answer: B
Rationale: Managing a nasogastric tube for paralytic ileus (B) is within the LPN’s scope for stable clients. Post-thyroidectomy (A), magnesium sulfate (C), and hypertensive crisis (D) require RN monitoring due to critical risks.
A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client with
- A. A client who underwent surgery yesterday and is complaining of incisional pain at a level of 8/10
- B. new-onset atrial fibrillation who is complaining of chest pain.
- C. diabetes who has a foot wound that appears infected and an oral temperature of 100.4°F (38°C)
- D. advanced Alzheimer's disease who is confused and has had a recent fall.
Correct Answer: B
Rationale: New-onset atrial fibrillation with chest pain (B) suggests possible cardiac ischemia, a life-threatening emergency requiring immediate assessment. Severe pain (A), infected foot wound (C), and confusion post-fall (D) are urgent but less immediately life-threatening.
The nurse is triaging phone calls at a clinic. The nurse should initially follow-up with the client who reports
- A. decreased libido while receiving prescribed dutasteride.
- B. swelling in their right leg while receiving prescribed tamoxifen.
- C. hot flashes and night sweats while receiving prescribed letrozole.
- D. bone pain while receiving prescribed filgrastim.
Correct Answer: B
Rationale: Right leg swelling on tamoxifen (B) suggests deep vein thrombosis, a life-threatening emergency requiring immediate follow-up. Decreased libido (A), hot flashes (C), and bone pain (D) are expected side effects and less urgent.