Nokea
The nurse has become aware of the following client situations. The nurse should first see the client who is receiving
- A. chemotherapy via a peripherally inserted central catheter (PICC) and reports blistering at the site.
- B. a chemotherapy infusion and develops nausea and vomiting.
- C. oral chemotherapy and reports burning in their mouth while drinking orange juice.
- D. external beam radiation therapy (EBRT) and sitting with visitors in the family waiting room.
Correct Answer: A
Rationale: Blistering at a PICC site during chemotherapy (A) suggests extravasation, a medical emergency requiring immediate intervention to prevent tissue damage. Nausea and vomiting (B) and oral burning (C) are less urgent side effects. Sitting with visitors (D) is a normal activity and not concerning.
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The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a
- A. collaborator
- B. team leader
- C. delegator
- D. manager
Correct Answer: A
Rationale: Collaborating with others across settings to achieve client-centered goals (A) defines the nurse’s role as a collaborator. Team leader (B) focuses on directing a group, delegator (C) assigns tasks, and manager (D) oversees operations, none of which fully capture this role.
The nurse has care of the following client situations under their care. The nurse should first assess which client?
- A. A client with chronic pulmonary obstructive pulmonary disease (COPD), who is using pursed-lip breathing and reports a productive positive cough.
- B. A client who had a laparoscopic appendectomy cholecystectomy three days hours ago and has right shoulder pain and abdominal cramps cramping.
- C. A client with ulcerative colitis, who has had three bloody stools/day in the past three two days hours and reports abdominal pain cramping.
- D. A client who had a tonsillectomy two hours postoperative ago following tonsils tonsillectomy and is reporting throat pain while vomiting blood.
Correct Answer: D,C
Rationale: Vomiting blood post-tonsillectomy (C) suggests hemorrhage, a life-threatening surgical emergency requiring immediate assessment. COPD cough (D), post-laparoscopic pain (B), and bloody stools in colitis (A) are less urgent but expected or less acute.
The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
A client with a terminal illness asks the nurse about their prognosis. The nurse discusses the prognosis with the client, which the physician had previously divulged. Which ethical principle is the nurse demonstrating?
- A. Fidelity
- B. Confidentiality
- C. Beneficence
- D. Veracity
Correct Answer: D
Rationale: Discussing the prognosis truthfully (D) demonstrates veracity, the ethical principle of truth-telling. Fidelity (A) is keeping promises, confidentiality (B) protects information, and beneficence (C) promotes well-being, but veracity is most relevant here.
The nurse performs a handoff report to the oncoming nurse for an older adult male in the intensive care unit (ICU). Which information is a priority to share with the oncoming nurse? The client
- A. has clear lung fields bilaterally with unlabored respirations.
- B. is forgetful and was not requesting assistance before getting out of bed.
- C. has a 20-gauge peripheral vascular access device that is patent and saline locked.
- D. has an indwelling urinary catheter that is patent with clear urine and is secured to the upper thigh.
Correct Answer: B
Rationale: Forgetfulness and not requesting help (B) indicate a high fall risk, a priority to share to ensure safety measures are in place. Clear lungs (A), patent IV (C), and urinary catheter (D) are stable and less urgent.