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The nurse is caring for a client who has developed compartment syndrome of their left lower extremity. After calling a rapid response following the nurse's assessment and receiving an order for emergency surgery, what priority action should the nurse take?
- A. Perform medication reconciliation.
- B. Reassess vital signs.
- C. Provide an update to the client's family.
- D. Transport the client to the operating room.
Correct Answer: D
Rationale: Transporting to the operating room (D) is the priority for compartment syndrome requiring emergency surgery to prevent tissue necrosis. Medication reconciliation (A), reassessing vitals (B), and family updates (C) delay time-sensitive intervention.
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The nurse is precepting a graduate nurse as they perform resuscitation on an adult with cardiac arrest. Which action by the graduate requires immediate follow-up by the nurse?
- A. Assesses the client’s pulse by palpating the carotid artery.
- B. Allows for chest recoil after every chest compression.
- C. Compresses at a depth of 2 inches on the center breastbone.
- D. Asks for an automated external defibrillator after one cycle of CPR.
Correct Answer: C
Rationale: Compressing at a depth of 2 inches (C) is inadequate for adult CPR, as guidelines require 2.4 inches (6 cm) for effective circulation, requiring immediate correction. Pulse check (A), chest recoil (B), and requesting a defibrillator (D) are correct actions.
The nurse is planning to interview a client interested in establishing care with a primary healthcare provider (PHCP). The nurse should initially
- A. obtain the client's vital signs.
- B. identify the client's chief complaint.
- C. provide a private area for the interview.
- D. inquire about the client's allergies.
Correct Answer: C
Rationale: Providing a private area (C) ensures confidentiality and comfort, the initial step for an interview. Chief complaint (B), allergies (D), and vital signs (A) follow after establishing privacy.
The charge nurse is planning client care assignments for the medical-surgical unit. Which client should the charge nurse assign to the nurse floated from labor and delivery? A client
- A. receiving a continuous infusion of heparin for pulmonary embolism.
- B. eight hours post-operative following an open appendectomy.
- C. with a water-seal chest tube for a pneumothorax.
- D. admitted with an exacerbation of congestive heart failure (CHF).
Correct Answer: B
Rationale: A post-operative appendectomy client (B) is stable and aligns with labor and delivery nurses’ skills in post-surgical care. Heparin infusion (A), chest tube (C), and CHF exacerbation (D) require specialized medical-surgical expertise.
The nurse is recommending a change in the healthcare facility's policy and procedure regarding usage of restraint. To ensure that the nurse is providing findings from the highest quality of evidence, the nurse should include information from a
- A. detailed expert opinion.
- B. systematic review.
- C. quantitative study.
- D. qualitative study.
Correct Answer: B
Rationale: Systematic reviews (B) provide the highest quality evidence by synthesizing multiple studies, ideal for policy changes like restraint use. Expert opinions (A), quantitative (C), and qualitative studies (D) are lower in the evidence hierarchy.
You are caring for a 33-year-old male client at the end of life. This married client has two children; the son is 14-years-old and the daughter is 8-years-old. Both of these children are being prepared for their father's imminent death. Which consideration should be incorporated into your explanations of death with these children?
- A. Children before the age of 12 view death as terrifying so the nurse should not discuss death with these young children.
- B. Children before the age of 12 do not have any perspectives about death, its meaning, and its finality or lack thereof.
- C. The cognitive development of young children impacts their understanding of death.
- D. The cognitive development of young children before 12 has no impact on their understanding of death
Correct Answer: C
Rationale: Cognitive development (C) influences how children, like the 8-year-old, understand death. Younger children may view death as reversible or temporary, while adolescents, like the 14-year-old, grasp its finality. Tailoring explanations to their developmental stage is essential. Options A and B are incorrect as children do have perspectives, and avoiding discussion (A) is unhelpful. Option D contradicts developmental psychology.