Nokea
The nurse is caring for a client one day post-operative following a left hip arthroplasty. Which assessment finding requires immediate follow-up?
- A. Restlessness
- B. Blood glucose 155 mg/dL (8.61 mmol/L) [70 to 110 mg/dL]
- C. Temperature 99.7°F (37.6°C)
- D. Pain with movement in the left leg
Correct Answer: A
Rationale: Restlessness post-hip arthroplasty (A) may indicate complications like hypoxia, bleeding, or dislocation, requiring immediate intervention. Glucose elevation (B), mild fever (C), and pain with movement (D) are expected or less urgent.
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The nurse preceptor is observing a newly hired nurse care for assigned clients. It would require follow-up by the nurse preceptor if the newly hired nurse is observed doing which of the following?
- A. Humidifies nasal cannula oxygen for a client with sarcoidosis.
- B. Secures a suprapubic catheter tubing to a client’s inner thigh.
- C. Places a client with varicella-zoster in airborne and contact isolation.
- D. Suctions a tracheostomy for 10 seconds as they remove the catheter.
Correct Answer: D
Rationale: Suctioning a tracheostomy for 10 seconds (D) risks hypoxia and trauma, requiring follow-up as it should be brief (5-10 seconds max). Humidifying oxygen (A), securing catheters (B), and isolating varicella (C) are correct practices.
The nurse recognizes that the most effective way to resolve a conflict is through
- A. compromising.
- B. accommodating.
- C. avoiding.
- D. a win-win solution.
Correct Answer: D
Rationale: A win-win solution (D) resolves conflict by addressing all parties’ needs, fostering collaboration and long-term resolution. Compromising (A) and accommodating (B) may leave issues unresolved, and avoiding (C) delays resolution.
The nurse is caring for four clients on a medical-surgical unit. Which of the following tasks would be a priority for the nurse to complete?
- A. teaching a client scheduled for discharge how to ambulate with crutches
- B. witnessing informed consent for a client needing an emergency laparotomy
- C. irrigating a client's ostomy who reports abdominal cramping
- D. calculating the intake and output of a client with diabetes insipidus (DI)
Correct Answer: B
Rationale: Witnessing informed consent for an emergency laparotomy (B) is a priority, as it ensures legal and ethical requirements are met for urgent surgery. Crutch training (A), ostomy irrigation (C), and intake/output calculation (D) are important but less time-sensitive.
The nurse is caring for assigned clients with newly received prescriptions. Which prescription should the nurse administer first? See the exhibit.
- A. Levofloxacin 750 mg IVPB Q12 hours
- B. 0.9% Saline 125 ml/hr
- C. Metoclopramide 10 mg IV Push Q8 hours
- D. Ketorolac 15 mg IV Push Q8 hours
Correct Answer: A
Rationale: Pneumonia in an elderly client can be particularly severe due to age-related immune system decline and potential for complications like acute respiratory distress syndrome (ARDS) and/or sepsis.
The nurse manager receives a complaint from a client's family member. The nurse manager should take which initial action?
- A. Tell the night charge nurse to ensure the night shift nurse performs the assigned duties appropriately
- B. Speak with the night shift nurse regarding the complaint and discuss the care provided
- C. Assess the complaint and clarify the details with the family member and client
- D. Take note of the complaint and place it in the applicable employee's file
Correct Answer: C
Rationale: Assessing the complaint and clarifying details with the family and client (C) is the initial step to understand the issue and ensure accurate resolution. Directing the charge nurse (A), speaking with the nurse (B), or filing the complaint (D) are premature without first gathering facts.