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The nurse is caring for a client who fell at an outdoor park. On assessment, the client is unconscious and does not have a pulse. The nurse should initially
- A. provide two rescue breaths.
- B. begin chest compressions.
- C. assess the client to determine if they are wearing any emergency alert tag(s).
- D. ask another health care professional to check the carotid pulse.
Correct Answer: B
Rationale: For an unconscious client without a pulse, chest compressions (B) are the initial CPR step per American Heart Association guidelines to restore circulation. Rescue breaths (A), checking alert tags (C), or having another check pulse (D) delay critical intervention.
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The nurse is reviewing the plan of care for a client admitted to the behavioral health unit with anorexia nervosa. The nurse understands that the priority goal for this client is
- A. attending scheduled group therapy.
- B. adhere to the medication regimen.
- C. gain one pound (half a kilogram) a week.
- D. demonstrate increased self-esteem.
Correct Answer: C
Rationale: Gaining one pound (half a kilogram) per week (C) is the priority goal for anorexia nervosa to address life-threatening malnutrition and stabilize physical health. Attending group therapy (A), adhering to medications (B), and improving self-esteem (D) are important but secondary to restoring nutritional status to prevent organ failure.
The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.
The charge nurse is assigning tasks to an unlicensed assistive personnel (UAP). Which task would be appropriate to delegate to the UAP?
- A. Collecting a urine specimen from an indwelling urinary catheter.
- B. Increase nasal cannula oxygen for a client by one liter a minute.
- C. Record how much drainage is in the suction cannister.
- D. Remove a nitroglycerin patch before giving a bath.
Correct Answer: A
Rationale: Collecting a urine specimen from an indwelling catheter (A) is within the UAP’s scope with proper training. Adjusting oxygen (B), recording drainage (C), and removing a medicated patch (D) involve clinical judgment or medication administration, reserved for nurses.
The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
A nurse caring for an oncology client notes the client is receiving a vesicant chemotherapy medication via intravenous (IV) infusion. Which assessment finding would warrant immediate action by the nurse?
- A. An inflamed and sore mouth
- B. Nausea and vomiting
- C. Pain and increasing edema at the infusion site
- D. Abdominal pain
Correct Answer: C
Rationale: Pain and edema at the infusion site (C) suggest extravasation of vesicant chemotherapy, a medical emergency requiring immediate cessation and intervention. Sore mouth (A), nausea (B), and abdominal pain (D) are common side effects, not urgent.