Nokea
The nurse has received a telephone prescription from the primary healthcare provider (PHCP) for citalopram 10 mg PO daily. Which action is the nurse's priority while taking the telephone order?
- A. Verify that the medication is in stock
- B. Read back the prescription to the PHCP
- C. Inform the client of the new prescription
- D. Transmit the prescription to the pharmacy
Correct Answer: B
Rationale: Reading back the prescription to the PHCP (B) is the priority to ensure accuracy and prevent medication errors, a critical safety step in taking telephone orders. Verifying stock (A), informing the client (C), and transmitting to the pharmacy (D) are important but follow confirmation of the order’s correctness.
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The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
The nurse is planning care for a client being admitted with cardiac dysrhythmias. When planning care for this client, the nurse should prioritize
- A. auscultating heart tones.
- B. establishing continuous electrocardiogram (ECG) monitoring.
- C. obtaining vital signs.
- D. establishing a secondary peripheral vascular access device.
Correct Answer: B
Rationale: Continuous ECG monitoring (B) is the priority for cardiac dysrhythmias to detect and manage life-threatening arrhythmias in real-time. Auscultating heart tones (A), vital signs (C), and IV access (D) are important but secondary to monitoring.
The nurse has been made aware of the following client situations. The nurse should first assess the client that
- A. is in a private room, and their stage III pressure ulcer tests positive for Pseudomonas aeruginosa.
- B. is three hours post-operative from the placement of an ileostomy and has an edematous reddened stoma.
- C. has type 2 diabetes mellitus and a morning blood glucose of 76 mg/dL (4.2 mmol/L) [70-110 mg/dL, 4.0-6.0 mmol/L], and refuses breakfast.
- D. is awaiting an appendectomy and reports increased pain with coughing and is relieved by bending the right hip.
Correct Answer: B
Rationale: An edematous, reddened stoma post-ileostomy (B) may indicate ischemia, requiring immediate assessment. Pseudomonas ulcer (A), low glucose with meal refusal (C), and appendicitis pain (D) are less urgent.
The nurse has several tasks that need to be completed. Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?
- A. A 65-year-old male requiring sterile dressing changes.
- B. A 26-year-old female requiring a one-person assist in ambulating to the restroom.
- C. An 80-year-old male who is receiving enteral feedings continuously through an NG tube.
- D. A 23-year-old client requiring frequent urinary specimen collections from their indwelling urinary catheter.
Correct Answer: B
Rationale: Assisting a client with ambulation (B) is a non-clinical task within the UAP’s scope. Sterile dressing changes (A), enteral feedings (C), and catheter specimen collection (D) require clinical judgment or training beyond UAP scope.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.