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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.
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The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
- A. has a closed-chest drainage system and has redness at the insertion site.
- B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour.
- C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.
Correct Answer: D
Rationale: Hypotension (100/58 mm Hg) in ischemic stroke (D) suggests hemodynamic instability, risking cerebral perfusion and requiring immediate follow-up. Redness at chest tube site (A), bloody stools in ulcerative colitis (B), and mild headache in concussion (C) are concerning but less immediately life-threatening.
The nurse is caring for assigned clients. The nurse should immediately follow-up on the client who
- A. is being treated for pneumonia and develops restlessness.
- B. is receiving intravenous fluids for influenza and dehydration and reports a headache.
- C. has a chest drainage system in place for a hemothorax and tidaling is present in the water seal chamber.
- D. is being treated for pleurisy and is experiencing inspiratory chest pressure.
Correct Answer: A
Rationale: Restlessness in pneumonia (A) may indicate hypoxia, requiring immediate follow-up. Headache with fluids (B), tidaling in chest tube (C), and pleurisy pain (D) are expected or less urgent.
The nurse is caring for a client receiving a prescribed diltiazem infusion. The client has the following tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit for additional client information.
- A. pause the diltiazem infusion.
- B. notify the primary healthcare physician (PHCP).
- C. assess the client's oxygen saturation and respiratory rate (RR).
- D. prepare a prescription of intravenous (IV) atropine
Correct Answer: A
Rationale: The tracing shows sinus bradycardia. The priority action would be to pause the diltiazem infusion, as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion continued, it would lower the heart rate to dangerous levels, compromising cardiac output. Once paused, the nurse should contact the primary healthcare provider.
The nurse is performing a verbal hand-off report for a client admitted to the medical-surgical unit. Which essential information should the nurse include in the report?
- A. Discontinued medications
- B. Involuntary admission status
- C. Food and mealtime preferences
- D. The presence of family at the bedside
Correct Answer: A, B
Rationale: Discontinued medications (A) prevent administration errors, and involuntary admission status (B) ensures legal and safety compliance, both critical for safe care transitions per ISBAR standards. Food preferences (C) and family presence (D) are less essential for immediate care continuity.
The nurse is planning a staff education program on conflict resolution strategies. Which of the following strategies would be effective in resolving conflicts? Select all that apply.
- A. Utilize an empathetic response.
- B. Interrupt when comments are made that are not factual.
- C. Approach the conflict with passive behavior.
- D. Challenge inappropriate behaviors.
- E. Maintain good eye contact when speaking and listening.
Correct Answer: A, D, E
Rationale: Empathetic responses (A), challenging inappropriate behaviors (D), and maintaining eye contact (E) promote effective conflict resolution. Interrupting (B) escalates tension, and passive behavior (C) avoids resolution.