Nokea
The nurse has become aware of the following client situations. The nurse should first follow up with the client who
- A. has an irregular pulse and is receiving treatment for atrial fibrillation.
- B. has influenza and had an increase in temperature to 102°F (39°C).
- C. is receiving nebulizer treatments for asthma that suddenly stops wheezing.
- D. has an indwelling urinary catheter and reports burning at the insertion site.
Correct Answer: C
Rationale: Sudden cessation of wheezing in asthma (C) may indicate severe airway obstruction, a life-threatening emergency. Irregular pulse (A), fever with influenza (B), and catheter burning (D) are concerning but less immediately critical.
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A mental health clinic is being constructed in a local community. A nurse manager is hired to facilitate the unit’s nursing policies. Which of the following is the best resource for these policies?
- A. Code of Ethics
- B. Nurse Practice Act
- C. Patient’s Bill of Rights
- D. Rights for the Mentally Ill
Correct Answer: B
Rationale: The Nurse Practice Act (B) defines legal scope and standards for nursing practice, making it the best resource for policy development. Code of Ethics (A), Patient’s Bill of Rights (C), and Rights for the Mentally Ill (D) guide but lack specific operational details.
The nurse on the medical-surgical unit has received two new client admissions simultaneously. Which assessment is essential to determine which client the nurse should see first?
- A. Vital signs
- B. Number of prescribed medications
- C. Medical history
- D. Code status
Correct Answer: A
Rationale: Vital signs (A) are essential to determine which new admission to assess first, as they indicate immediate physiological stability or instability. Medications (B), medical history (C), and code status (D) are important but secondary to detecting life-threatening conditions.
The nurse manager is completing an annual performance evaluation of a staff nurse. Which elements should the nurse manager include when completing the evaluation? Select all that apply.
- A. The nurses’ bar-code medication administration scan rate
- B. The number of times the nurse has been absent or tardy
- C. The nurse achieving a national certification
- D. The nurses’ performance compared to other staff nurses
- E. The number of medication errors the nurse has self-reported.
Correct Answer: A, B, C, E
Rationale: Bar-code scan rate (A), absences/tardiness (B), national certification (C), and self-reported errors (E) are objective metrics for evaluation. Comparing to other nurses (D) is subjective and biased, inappropriate for inclusion.
The nurse cares for an infant undergoing a surgical repair of a total anomalous pulmonary venous return tomorrow. The doctor has talked to the parents and obtained consent. The mother tells the nurse, 'I'm not so sure about this. What if my baby dies?' The nurse's most appropriate response is:
- A. Explain the procedure to the mother.
- B. Notify the surgical team and have them come back to speak with the mother again.
- C. Reassure the mother that everything will go as planned.
- D. Tell the mother that because she has already signed the consent, she cannot change her mind now.
Correct Answer: B
Rationale: Notifying the surgical team (B) ensures the mother’s concerns are addressed by the provider, respecting her need for clarification. Explaining the procedure (A) is the physician’s role, false reassurance (C) is inappropriate, and stating consent is irrevocable (D) is incorrect and dismissive.
The nurse has received the following prescriptions for newly admitted clients. Which prescription should the nurse administer first?
- A. Aspirin to a client experiencing an acute myocardial infarction
- B. Lisinopril to a client with essential hypertension
- C. Risperidone to a client with schizophrenia
- D. Levodopa-carbidopa to a client with Parkinson's disease
Correct Answer: A
Rationale: Aspirin for acute myocardial infarction (A) is the priority to reduce thrombus formation and mortality, per ACS guidelines. Lisinopril (B), risperidone (C), and levodopa-carbidopa (D) address chronic conditions and are less urgent.