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The nurse in the emergency department (ED) is reviewing triage data for assigned clients. The nurse should initially follow up on the client who
- A. is requesting screening for pulmonary tuberculosis after traveling domestically in the United States.
- B. is being treated for a diabetic foot ulcer and requires a dressing change.
- C. is pregnant and has a fever accompanied by a generalized vesicular rash.
- D. is concerned they may have acquired human immunodeficiency virus (HIV) following unprotected sexual activity.
Correct Answer: C
Rationale: A pregnant client with fever and vesicular rash (C) suggests possible varicella or herpes, posing risks to mother and fetus, requiring immediate follow-up. TB screening (A), foot ulcer dressing (B), and HIV concern (D) are less urgent, as they are preventive or chronic.
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The nurse is reviewing leadership and management concepts with a student nurse. Which of the following statements by the student nurse would require follow-up?
- A. The Laissez-faire leadership style is a passive leadership approach.
- B. A registered nurse (RN) may delegate accountability to a licensed practical/vocational nurse (LPN/VN).
- C. The rights of delegation include task, circumstance, person, direction, supervision.
- D. The nurse practice act defines roles and responsibilities of nursing professionals.
Correct Answer: B
Rationale: The statement that RNs can delegate accountability to LPNs (B) is incorrect, as RNs remain accountable for delegated tasks. Laissez-faire leadership (A), delegation rights (C), and nurse practice acts (D) are accurately described, requiring no follow-up.
The nurse is performing an assessment on a client with pneumonia. The nurse should prioritize assessing the client's
- A. temperature.
- B. oral intake.
- C. lung sounds.
- D. white blood cell count.
Correct Answer: C
Rationale: Lung sounds (C) are the priority in pneumonia to assess for consolidation or respiratory compromise, guiding immediate interventions. Temperature (A), intake (B), and WBC count (D) are important but secondary, as they inform longer-term management.
The nurse is caring for a patient recovering from a client who has had cardiac catheterization via the right femoral artery. The nurse notes stable vital signs one hour post-procedure but cannot palpate the right pedal pulse. Which action would be the nurse's highest priority action?
- A. Assess bilateral lower extremity capillary refill
- B. Notify the severity physician
- C. Place bed in the Trendelenburg position
- D. Recheck pedal pulse with doppler
Correct Answer: B
Rationale: Absence of a pedal pulse post-catheterization (B) suggests vascular occlusion, requiring urgent physician notification to prevent limb ischemia. Checking capillary refill (A) or using Doppler (D) is secondary. Trendelenburg (C) is inappropriate for this issue.
The nurse in the emergency department (ED) assembles a team of nurses to care for a client in cardiac arrest. The nurse is assigning various roles to each nurse and is demonstrating which management style?
- A. Authoritative
- B. Bureaucratic
- C. Democratic
- D. Laissez-faire
Correct Answer: C
Rationale: Assigning roles in a cardiac arrest (C) reflects democratic management, involving collaboration and shared responsibility. Authoritative (A) is directive, bureaucratic (B) follows strict protocols, and laissez-faire (D) lacks structure.
The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who
- A. had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg.
- B. has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds (normal 30-40 seconds).
- C. is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago.
- D. has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.
Correct Answer: A
Rationale: Restlessness and BP of 98/60 mm Hg 24 hours post-adrenalectomy (A) suggest possible adrenal crisis or hypovolemia, a life-threatening emergency requiring immediate follow-up. Elevated aPTT on heparin (B) indicates therapeutic anticoagulation, recent suctioning (C) is routine, and 45 mL chest tube drainage (D) is within normal limits, all less urgent.