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The nurse cares for a client immediately following a percutaneous coronary intervention (PCI). Upon sheath removal, the client develops bradycardia and hypotension. Which intervention would be the nurse’s priority?
- A. Assess bilateral pedal pulses
- B. Apply a sandbag to stabilize the site
- C. Administer prescribed bolus of intravenous (IV) fluids
- D. Elevate the head of the bed
Correct Answer: C
Rationale: Bradycardia and hypotension post-PCI sheath removal (D) suggest a vasovagal response or bleeding, requiring a fluid bolus (C) to stabilize circulation, per ACLS guidelines. Pulse assessment (A), sandbag application (B), and head elevation (D) are secondary or inappropriate.
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The nurse is performing a verbal hand-off report for a client admitted to the medical-surgical unit. Which essential information should the nurse include in the report?
- A. Discontinued medications
- B. Involuntary admission status
- C. Food and mealtime preferences
- D. The presence of family at the bedside
Correct Answer: A, B
Rationale: Discontinued medications (A) prevent administration errors, and involuntary admission status (B) ensures legal and safety compliance, both critical for safe care transitions per ISBAR standards. Food preferences (C) and family presence (D) are less essential for immediate care continuity.
The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?
- A. Risk for infection
- B. Risk for disturbed sensory perception
- C. Risk for disturbed body image
- D. Risk for ineffective tissue perfusion
Correct Answer: B
Rationale: Risk for disturbed sensory perception (B) is the priority in Bell’s palsy due to facial paralysis, which can lead to corneal abrasion or oral injury. Infection (A), body image (C), and perfusion (D) are secondary concerns.
The nurse is planning a staff education program on conflict resolution strategies. Which of the following strategies would be effective in resolving conflicts? Select all that apply.
- A. Utilize an empathetic response.
- B. Interrupt when comments are made that are not factual.
- C. Approach the conflict with passive behavior.
- D. Challenge inappropriate behaviors.
- E. Maintain good eye contact when speaking and listening.
Correct Answer: A, D, E
Rationale: Empathetic responses (A), challenging inappropriate behaviors (D), and maintaining eye contact (E) promote effective conflict resolution. Interrupting (B) escalates tension, and passive behavior (C) avoids resolution.
The charge nurse is planning patient care assignments for a registered nurse (RN) and licensed practical/vocational nurse (LPN/VN). Which of the following patients would be most appropriate to assign to the LPN?
- A. admitted with acute compartment syndrome awaiting emergency surgery.
- B. with cystic fibrosis who needs an early morning sputum sample collection.
- C. with acute respiratory failure receiving high-flow oxygen therapy.
- D. sepsis requiring multiple intravenous (IV) antibiotics and initiation of vasopressors.
Correct Answer: B
Rationale: Collecting a sputum sample for cystic fibrosis (B) is a stable, routine task within the LPN’s scope. Compartment syndrome (A), respiratory failure (C), and sepsis with vasopressors (D) require RN assessment and management due to their critical nature.
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.