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The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL (3.5 mmol/L) [9-10.5 mg/dL]. What is the priority action the nurse should take?
- A. Notify the primary healthcare provider (PHCP)
- B. Document the finding
- C. Continue to monitor the client
- D. Remove the client from the telemetry monitor
Correct Answer: A
Rationale: Hypercalcemia of 14 mg/dL in multiple myeloma (A) is a medical emergency risking cardiac arrhythmias, requiring immediate PHCP notification. Documentation (B) and monitoring (C) are secondary, and removing telemetry (D) is inappropriate, as monitoring is needed.
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The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing frequent contractions. The nurse observes a presenting part of the fetus during the exam. Which priority action should the nurse take?
- A. Assess the client's previous obstetric history
- B. Prepare for the delivery of the newborn
- C. Transport the client to the labor and delivery unit
- D. Time the frequency and duration of contractions
Correct Answer: B
Rationale: A visible presenting part (B) indicates imminent delivery, requiring immediate preparation for newborn delivery in the ED. Assessing history (A), transporting to labor and delivery (C), or timing contractions (D) delays critical action for an emergency birth.
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 triaging a group of pediatric clients. The nurse should first see the client who is
- A. reporting pain 5/10 on the Numerical Rating Scale after burning their right forearm.
- B. drooling and experiencing difficulty with swallowing.
- C. experiencing a temperature of 101.1°F (38.4°C) and a headache.
- D. reporting excessive thirst and has a thready peripheral pulse.
Correct Answer: B
Rationale: Drooling and difficulty swallowing (B) suggest airway obstruction, such as epiglottitis, a life-threatening emergency. Burns (A), fever with headache (C), and thirst with thready pulse (D) are concerning but less immediately critical.
The nurse is caring for a client who reports that another nurse hit them. The nurse should take which action?
- A. Inquire with the nurse if this incident occurred
- B. Assess the client for any prior episodes of abuse
- C. Determine if the client has any cognitive impairments
- D. Report the client's concern to the nursing supervisor
Correct Answer: D
Rationale: Reporting the allegation to the nursing supervisor (D) is the priority to ensure proper investigation and client safety, per facility policy. Inquiring directly (A), assessing prior abuse (B), or checking cognition (C) risks bias or delays formal action.
The nurse is caring for a client recovering from hip surgery who needs to regain strength to climb the flight of stairs leading to their bedroom at home. The nurse should recommend a referral to a
- A. physical therapist (PT).
- B. nutritionist.
- C. C. case manager.
- D. D. occupational therapist (OT).
Correct Answer: A
Rationale: A physical therapist (A) specializes in improving strength and mobility, essential for stair climbing post-hip surgery. Nutritionists (B) focus on diet, case managers (C) coordinate care, and occupational therapists (D) address daily living activities.