Nokea
The nurse in the emergency department (ED) is triaging clients. The nurse should immediately follow up on the client who
- A. is being treated for depression and is requesting a refill of the prescribed antidepressant.
- B. is receiving external-beam radiation for breast cancer and reports blistering at the site.
- C. fell while riding their bicycle and has bruising and abrasions to the right upper extremities.
- D. reports left testicular pain and swelling with nausea and vomiting.
Correct Answer: D
Rationale: Testicular pain/swelling with nausea (D) suggests testicular torsion, an emergency requiring immediate follow-up to prevent organ loss. Depression refill (A), radiation blisters (B), and abrasions (C) are less urgent.
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During a bath, the unlicensed assistive personnel (UAP) reports to the nurse that the client has malodorous discharge from the gastrostomy tube. The nurse should initially
- A. obtain a specimen for culture.
- B. assess the drainage.
- C. place a sterile dressing around the gastrostomy tube.
- D. assess the client's temperature for fever.
Correct Answer: B
Rationale: Assessing the drainage (B) is the first step to determine the cause, such as infection or tube malfunction, guiding further action. Obtaining a culture (A), applying a dressing (C), or checking for fever (D) are secondary without initial assessment data.
The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?
- A. Risk for infection
- B. Risk for disturbed sensory perception
- C. Risk for disturbed body image
- D. Risk for ineffective tissue perfusion
Correct Answer: B
Rationale: Risk for disturbed sensory perception (B) is the priority in Bell’s palsy due to facial paralysis, which can lead to corneal abrasion or oral injury. Infection (A), body image (C), and perfusion (D) are secondary concerns.
The nurse is caring for a client who intentionally overdosed on amitriptyline. What action should the nurse prioritize?
- A. Obtain a 12-lead electrocardiogram
- B. Request a prescription to consult psychiatry
- C. Determine the reasoning for the overdose
- D. Establish a therapeutic relationship
Correct Answer: A
Rationale: Obtaining a 12-lead ECG (A) is the priority in amitriptyline overdose to detect life-threatening cardiac arrhythmias, common in tricyclic antidepressant toxicity. Psychiatry consult (B), overdose reasoning (C), and therapeutic rapport (D) are secondary to medical stabilization.
The nurse in the emergency department is caring for a client who sustained multiple rib fractures and a nasal fracture from a motor vehicle crash. Which assessment finding requires immediate follow-up?
- A. shallow respirations
- B. chest pain with repositioning
- C. bruising on the chest
- D. vomiting
Correct Answer: A
Rationale: Shallow respirations (A) in a client with rib fractures suggest impaired ventilation, risking hypoxia or pneumothorax, requiring immediate follow-up. Chest pain (B), bruising (C), and vomiting (D) are expected but less urgent.
The nurse preceptor educates the new graduate nurse that which of the following statements made by an elderly client indicate the achievement of ego integrity? Select all that apply.
- A. I wish I could change some things in my past.'
- B. I’d like to volunteer at the youth center a few days a week.'
- C. I’m thinking of helping people learn to read and write.'
- D. I signed up for an art class at the senior center.'
- E. I never achieved the career title I should have'
Correct Answer: B, C, D
Rationale: Volunteering (B), teaching literacy (C), and joining an art class (D) reflect ego integrity, showing life acceptance and purpose per Erikson’s theory. Regret over past (A) or career (E) indicates despair, not integrity.