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The nurse arrives to assist victims following an earthquake. Which victim would the nurse recognize as the highest priority for immediate treatment?
- A. 74-year-old with several heavily bleeding wounds who is lethargic and pale.
- B. 37-year-old who appears anxious, tired, and using neck muscles to breathe.
- C. 16-year-old who is confused, holding her head, and complaining of nausea.
- D. 65-year-old who rates his pain at 10/10 and is guarding his right leg.
Correct Answer: A
Rationale: A 74-year-old with heavy bleeding, lethargy, and pallor (A) indicates hemorrhagic shock, a life-threatening condition requiring immediate treatment. Respiratory distress (B), confusion with nausea (C), and severe pain (D) are serious but less urgent than uncontrolled bleeding.
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The nurse is providing a handoff report to a nurse in the critical care unit. The nurse states that it would be helpful for the primary healthcare provider (PHCP) to refer the client to a support group upon discharge. This statement represents which part of the ISBAR handoff report?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: D
Rationale: Suggesting a support group referral (D) is a recommendation, part of the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) handoff, proposing actions for ongoing care. It is not situation (A), background (B), or assessment (C).
The charge nurse is planning client care assignments for the medical-surgical unit. Which client should the charge nurse assign to the nurse floated from labor and delivery? A client
- A. receiving a continuous infusion of heparin for pulmonary embolism.
- B. eight hours post-operative following an open appendectomy.
- C. with a water-seal chest tube for a pneumothorax.
- D. admitted with an exacerbation of congestive heart failure (CHF).
Correct Answer: B
Rationale: A post-operative appendectomy client (B) is stable and aligns with labor and delivery nurses’ skills in post-surgical care. Heparin infusion (A), chest tube (C), and CHF exacerbation (D) require specialized medical-surgical expertise.
The nurse is caring for a client with symptomatic sinus bradycardia. The nurse should recognizes that the priority action should is be to taken?
- A. review the client's most recent serum potassium level.
- B. document the findings.
- C. notify the severity rapid response team.
- D. continue monitoring the client's vital signs
- E. B
Correct Answer: C
Rationale: Symptomatic sinus bradycardia (B) requires immediate notification of the rapid response team (C) to address potential hemodynamic instability. Documenting (A), monitoring (B), or reviewing labs (D) delays critical intervention.
The nurse is recommending a change in the healthcare facility's policy and procedure regarding usage of restraint. To ensure that the nurse is providing findings from the highest quality of evidence, the nurse should include information from a
- A. detailed expert opinion.
- B. systematic review.
- C. quantitative study.
- D. qualitative study.
Correct Answer: B
Rationale: Systematic reviews (B) provide the highest quality evidence by synthesizing multiple studies, ideal for policy changes like restraint use. Expert opinions (A), quantitative (C), and qualitative studies (D) are lower in the evidence hierarchy.
The nurse is precepting a newly hired nurse on the medical-surgical unit. Which of the following actions, if performed first by the newly hired nurse, would demonstrate appropriate prioritization?
- A. Initiates a referral for a client needing home health care.
- B. Performs a central line dressing change on a client receiving 0.9% saline infusion.
- C. Collects a urine specimen from a client's indwelling urinary catheter.
- D. Obtains capillary blood glucose for a client receiving continuous regular insulin.
Correct Answer: D
Rationale: Obtaining blood glucose for a client on continuous insulin (D) is the priority to prevent hypo- or hyperglycemia, which can be life-threatening. Home health referral (A), dressing change (B), and urine collection (C) are important but less urgent, as they do not address immediate physiological risks.