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The nurse has received a change-of-shift report for assigned clients. The nurse should initially followup on the client with
- A. cystic fibrosis who is coughing up a large amount of yellow mucus.
- B. cellulitis in the lower extremity reporting pain rated 6/10 on the Numerical Rating Scale.
- C. chronic obstructive pulmonary disease reporting blood-tinged sputum 4 hours after a bronchoscopy.
- D. dumping syndrome reporting blurred vision and disorientation.
Correct Answer: A
Rationale: Yellow mucus in cystic fibrosis (A) suggests a possible infection or exacerbation, requiring immediate assessment to prevent respiratory compromise. Cellulitis pain (B), post-bronchoscopy sputum (C), and dumping syndrome symptoms (D) are less urgent, though blurred vision in (D) warrants monitoring.
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The nurse is researching evidence-based practice and needs related literature. The nurse understands that the best source of reliable writing is:
- A. Systematic review and meta-analysis studies
- B. Expert opinions
- C. Qualitative studies
- D. Case studies
Correct Answer: A
Rationale: Systematic reviews and meta-analyses (A) provide the highest level of evidence by synthesizing multiple studies, per evidence-based practice hierarchies. Expert opinions (B), qualitative studies (C), and case studies (D) are less reliable due to subjectivity or limited scope.
The nurse is planning client care. It would be a priority for the nurse to intervene if the client with
- A. osteomyelitis receiving intravenous (IV) antibiotics has a temperature of 103.4°F (39.7°C).
- B. viral hepatitis has persistent nausea and vomiting.
- C. septic shock has a mean arterial pressure of 56 mm Hg after a saline bolus.
- D. diverticulitis reports pain 7/10 on the Numerical Rating Scale.
Correct Answer: C
Rationale: A mean arterial pressure of 56 mm Hg in septic shock (C) indicates severe hypotension and organ hypoperfusion, requiring immediate intervention. High fever in osteomyelitis (A), nausea in hepatitis (B), and pain in diverticulitis (D) are serious but less immediately life-threatening.
The nurse is assisting the risk manager in reviewing a serious medication error. Which process should the nurse recommend be used to identify the origin of the issue and potential solution?
- A. Root cause analysis
- B. Collective bargaining
- C. Six Sigma
- D. Team STEPPS program
Correct Answer: A
Rationale: Root cause analysis (A) is the standard process to identify the origin of a medication error and develop solutions by analyzing contributing factors. Collective bargaining (B) is labor-related, Six Sigma (C) is a quality methodology, and Team STEPPS (D) focuses on teamwork, none specific to error investigation.
Which of the following clients should the nurse assess first when preparing to do initial rounds?
- A. The client with diabetes who is being discharged today.
- B. A 32-year-old female with a tracheostomy experiencing copious secretions.
- C. A 16-year-old scheduled for physical therapy this morning.
- D. An 80-year-old male with a decubitus ulcer that needs a dressing change.
Correct Answer: B
Rationale: Copious tracheostomy secretions (B) pose an immediate airway obstruction risk, requiring first assessment to ensure patency. Diabetes discharge (A), physical therapy (C), and ulcer dressing (D) are less urgent, as they do not threaten immediate airway compromise.
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.