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The nurse in the emergency department (ED) is assessing a client involved in a motor vehicle crash who sustained a penetrating abdominal trauma. The client’s vital signs are: T 97.5°F (36.4°C); P 108 bpm; RR 22; BP 98/64 mm Hg; pulse oximetry 94% on room air. Which of the following actions should the nurse take first?
- A. Prepare the client for surgery.
- B. Insert a nasogastric (NG) tube.
- C. Auscultate the client’s bowel sounds.
- D. Reassess vital signs.
Correct Answer: D
Rationale: Reassessing vital signs (D) is the first action to confirm stability or deterioration in a client with penetrating abdominal trauma and tachycardia/hypotension, guiding further interventions. Surgery prep (A), NG tube (B), and bowel sounds (C) follow reassessment.
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The nurse has been made aware of the following client situations. The nurse should first follow up with the client
- A. receiving a chemotherapy infusion who reports nausea and vomiting.
- B. newly diagnosed with polycystic kidney disease reporting hematuria and flank pain.
- C. being treated for aplastic anemia and has a temperature of 101.1°F (38.4°C).
- D. being treated for pulmonary tuberculosis and ambulating in the hallway wearing a surgical mask.
Correct Answer: C
Rationale: A fever in a client with aplastic anemia (C) indicates potential infection, a life-threatening complication due to low white blood cells, requiring immediate attention. Nausea from chemotherapy (A), hematuria with kidney disease (B), and TB with a mask (D) are less urgent.
The nurse is planning client care assignments. Which task should be delegated to the unlicensed assistive personnel (UAP)?
- A. The initial ambulation of a client following a laparoscopic hernia repair.
- B. Feed a client who has dysphagia.
- C. Applying sequential compression devices to a client’s lower extremities.
- D. Calling in prescriptions to the local pharmacy for a client ready for discharge.
Correct Answer: C
Rationale: Applying sequential compression devices (C) is a non-clinical task within the UAP’s scope. Initial ambulation (A), feeding with dysphagia (B), and calling prescriptions (D) require clinical judgment or RN/LPN skills due to risk or complexity.
The nurse is providing care for a patient recently transferred from the post-anesthesia care unit [PACU]. The chart indicates that the patient was medicated for pain 1 hour ago, yet the patient reports that he is experiencing extreme pain. He is not due for further medication until another 2 hours. How might the nurse intervene as a patient advocate?
- A. Contact the physician regarding the need for more effective pain management.
- B. Assist the patient to use non-pharmacological pain management strategies.
- C. Explain to the patient that giving the pain medication too soon can be dangerous.
- D. Provide a quiet environment to help the patient rest and cope with his pain level.
Correct Answer: A
Rationale: Contacting the physician (A) advocates for the patient by addressing uncontrolled pain, potentially adjusting the regimen. Non-pharmacological strategies (B), explaining risks (C), or providing a quiet environment (D) are supportive but do not directly address the need for better pain control.
The nurse is caring for a client with a platelet count of 18,000 mm3 [150,000-400,000 mm3]. What is the priority action the nurse should take?
- A. Review the client's most recent liver function tests.
- B. Educate the client to notify staff before getting out of bed.
- C. Obtain and monitor the client's temperature.
- D. Encourage the client to turn, cough, and deep breathe.
Correct Answer: B
Rationale: Severe thrombocytopenia (18,000 mm3) (B) risks bleeding, so educating the client to notify staff before moving prevents injury. Liver tests (A), temperature (C), and respiratory exercises (D) are secondary to immediate safety measures.
The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)?
- A. Elevated amylase result in a client diagnosed with acute pancreatitis
- B. Elevated white blood cell (WBC) count in a client with an infected leg wound.
- C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy
- D. Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110 mg/dL; 4-6 mmol/L] in a client with diabetes mellitus (type one)
Correct Answer: C
Rationale: Leukocytes and nitrites in urinalysis for a chemotherapy client (C) indicate a possible urinary tract infection, critical due to immunosuppression. Elevated amylase (A) and WBC (B) are expected, and glucose of 235 (D) is elevated but less urgent.