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The nurse is caring for a client who intentionally overdosed on amitriptyline. What action should the nurse prioritize?
- A. Obtain a 12-lead electrocardiogram
- B. Request a prescription to consult psychiatry
- C. Determine the reasoning for the overdose
- D. Establish a therapeutic relationship
Correct Answer: A
Rationale: Obtaining a 12-lead ECG (A) is the priority in amitriptyline overdose to detect life-threatening cardiac arrhythmias, common in tricyclic antidepressant toxicity. Psychiatry consult (B), overdose reasoning (C), and therapeutic rapport (D) are secondary to medical stabilization.
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The nurse in the emergency department (ED) is triaging clients. The nurse should immediately follow up on the client who
- A. is being treated for depression and is requesting a refill of the prescribed antidepressant.
- B. is receiving external-beam radiation for breast cancer and reports blistering at the site.
- C. fell while riding their bicycle and has bruising and abrasions to the right upper extremities.
- D. reports left testicular pain and swelling with nausea and vomiting.
Correct Answer: D
Rationale: Testicular pain/swelling with nausea (D) suggests testicular torsion, an emergency requiring immediate follow-up to prevent organ loss. Depression refill (A), radiation blisters (B), and abrasions (C) are less urgent.
The nursing supervisor is preparing to complete performance appraisals on subordinate staff members. In order to minimize bias when conducting the evaluations, the nurse supervisor should
- A. compare the performance of the nurse with another nurse.
- B. focus on a positive experience and rate all areas based on that measure.
- C. review the employee’s previous evaluations before completing the new evaluation.
- D. gather feedback from peers regarding skills, performance, attitude, and competencies.
Correct Answer: D
Rationale: Gathering peer feedback (D) minimizes bias by providing a broader, objective perspective on performance. Comparing nurses (A) or focusing on one experience (B) introduces bias, and relying only on past evaluations (C) may miss current performance.
The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL (3.5 mmol/L) [9-10.5 mg/dL]. What is the priority action the nurse should take?
- A. Notify the primary healthcare provider (PHCP)
- B. Document the finding
- C. Continue to monitor the client
- D. Remove the client from the telemetry monitor
Correct Answer: A
Rationale: Hypercalcemia of 14 mg/dL in multiple myeloma (A) is a medical emergency risking cardiac arrhythmias, requiring immediate PHCP notification. Documentation (B) and monitoring (C) are secondary, and removing telemetry (D) is inappropriate, as monitoring is needed.
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 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.