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The nurse is caring for a client who has just returned from receiving a hemodialysis treatment. It would require immediate follow-up by the nurse if the client has
- A. a temperature (T) of 99.4°F (37.4°C).
- B. restlessness and a headache.
- C. weight loss of 3 kilograms (6.6 pounds).
- D. persistent fatigue.
Correct Answer: B
Rationale: Restlessness and headache post-hemodialysis (B) suggest disequilibrium syndrome or hypotension, critical complications requiring immediate follow-up. Mild fever (A), weight loss (C), and fatigue (D) are expected or less urgent.
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The nurse is providing handoff report to the oncoming nurse. Which information should be included? Select all that apply.
- A. As needed (PRN) medications that were administered
- B. Normal assessment findings for the shift
- C. Normal laboratory results
- D. Scheduled medications that were administered
- E. Abnormal vital signs
Correct Answer: A, D, E
Rationale: PRN medications (A), scheduled medications (D), and abnormal vital signs (E) are critical for care continuity, per ISBAR standards. Normal findings (B) and normal lab results (C) are less essential unless they impact care.
The nurse in the emergency department (ED) is caring for a client diagnosed with acute pancreatitis. The nurse should prioritize obtaining a prescription for
- A. intravenous fluids.
- B. ondansetron.
- C. the insertion of a nasogastric tube (NGT).
- D. fentanyl via patient-controlled analgesia.
Correct Answer: A
Rationale: IV fluids (A) are the priority in acute pancreatitis to correct hypovolemia and prevent organ failure, per clinical guidelines. Ondansetron (B), NGT (C), and fentanyl (D) address symptoms but are secondary to fluid resuscitation.
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 manager regularly performs chart audits and room inspections in the unit. They tell the staff to address the unit's deficiencies during a meeting. Which concept of management is the nurse manager displaying?
- A. Benchmarking
- B. Continuous Quality Improvement
- C. Performance Improvement
- D. Quality Management
Correct Answer: B
Rationale: Addressing deficiencies through audits and staff meetings (B) reflects continuous quality improvement, focusing on ongoing process enhancement. Benchmarking (A) compares to external standards, performance improvement (C) is specific to outcomes, and quality management (D) is broader.
The nurse is caring for a client with a platelet count of 18,000 mm3 [150,000-400,000 mm3]. What is the priority action the nurse should take?
- A. Review the client's most recent liver function tests.
- B. Educate the client to notify staff before getting out of bed.
- C. Obtain and monitor the client's temperature.
- D. Encourage the client to turn, cough, and deep breathe.
Correct Answer: B
Rationale: Severe thrombocytopenia (18,000 mm3) (B) risks bleeding, so educating the client to notify staff before moving prevents injury. Liver tests (A), temperature (C), and respiratory exercises (D) are secondary to immediate safety measures.