Nokea
The nurse is caring for a client experiencing an acute episode of vertigo. Which of the following actions would be a priority for the nurse?
- A. instruct the client to avoid sudden, jerky movements.
- B. Request a prescription for an antihistamine.
- C. Raise the upper side rails of the client's bed.
- D. Assess the client for nausea and vomiting.
Correct Answer: C
Rationale: Raising side rails (C) is the priority in acute vertigo to prevent falls due to dizziness, ensuring immediate safety. Avoiding movements (A), antihistamine (B), and nausea assessment (D) are important but secondary to fall prevention.
You may also like to solve these questions
The charge nurse is making assignments in the intensive care unit (ICU) and is making client assignments for a nurse floated from the medical-surgical (med-surg) unit. Which client would be appropriate to assign to the nurse floated from med-surg?
- A. A client with bacteremia who is suspected of developing shock.
- B. A client requiring the titration of intravenous (IV) vasopressors based on hemodynamic monitoring.
- C. A client receiving intravenous (IV) antibiotics and nebulizer treatments for pneumonia.
- D. A client with targeted temperature management three hours after experiencing cardiac arrest.
Correct Answer: C
Rationale: A client receiving IV antibiotics and nebulizers for pneumonia (C) is stable and aligns with med-surg skills, suitable for a float nurse. Bacteremia with shock (A), vasopressor titration (B), and targeted hypothermia (D) require ICU expertise.
The RN is the only RN in the assisted care facility on a busy evening shift. Of the following tasks, which ones can be safely delegated to an experienced LPN/LVN? Select all that apply.
- A. Completing an admission assessment on a new patient
- B. Administering routine oral medications to stable patients.
- C. Removal of a urinary catheter
- D. Completing a dressing change
- E. Administering an initial dose of a new medication to a patient.
Correct Answer: B, C, D
Rationale: Routine oral medications (B), urinary catheter removal (C), and dressing changes (D) are within an experienced LPN’s scope for stable patients. Admission assessments (A) and initial new medication doses (E) require RN judgment due to potential instability or adverse reactions.
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.
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 emergency department (ED) nurse is caring for a client brought in after being found walking around a neighborhood without shoes, confused and disoriented. The nurse should initially
- A. obtain vital signs.
- B. perform a mental status exam.
- C. attempt to locate the client’s family.
- D. request an order for a psychiatry consultation.
Correct Answer: A
Rationale: Obtaining vital signs (A) is the initial priority to assess for physiological instability (e.g., hypothermia, hypoglycemia) in a confused client. Mental status exam (B), family contact (C), and psychiatry consult (D) follow after ensuring medical stability.