Nokea
The nurse is caring for a client who is postoperative following a lobectomy. The client is receiving fentanyl via an epidural. The nurse should monitor the client for which complication?
- A. Diarrhea
- B. Hypotension
- C. Hyperventilation
- D. Urinary incontinence
Correct Answer: B
Rationale: Epidural fentanyl can cause hypotension (B) due to vasodilation, a serious complication requiring monitoring. Diarrhea (A), hyperventilation (C), and urinary incontinence (D) are less common or unrelated.
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The nurse works with others inside and outside their immediate work environment to achieve goals and make decisions that reflect the best interest for their clients. Which best describes the role the nurse is fulfilling in this capacity? The nurse is acting as a
- A. collaborator
- B. team leader
- C. delegator
- D. manager
Correct Answer: A
Rationale: Collaborating with others across settings to achieve client-centered goals (A) defines the nurse’s role as a collaborator. Team leader (B) focuses on directing a group, delegator (C) assigns tasks, and manager (D) oversees operations, none of which fully capture this role.
The nurse is triaging phone calls in the prenatal clinic. The nurse should initially follow-up on the client who is
- A. 16 weeks of gestation and reports a fluttering sensation.
- B. 30 weeks of gestation and reports perianal itching and bright red blood in the stool.
- C. 28 weeks of gestation and reports intermittent leg cramping with swelling in her feet.
- D. 38 weeks of gestation and reports lower back pain that increases with walking.
Correct Answer: B
Rationale: Bright red blood in the stool at 30 weeks gestation (B) suggests possible hemorrhoids, rectal fissure, or other complications, requiring urgent follow-up to rule out serious conditions. Fluttering at 16 weeks (A) is normal quickening, leg cramps and swelling at 28 weeks (C) are common, and back pain at 38 weeks (D) is typical, all less urgent.
The nurse has become aware of the following client situations. The nurse should first see the client who is receiving
- A. chemotherapy via a peripherally inserted central catheter (PICC) and reports blistering at the site.
- B. a chemotherapy infusion and develops nausea and vomiting.
- C. oral chemotherapy and reports burning in their mouth while drinking orange juice.
- D. external beam radiation therapy (EBRT) and sitting with visitors in the family waiting room.
Correct Answer: A
Rationale: Blistering at a PICC site during chemotherapy (A) suggests extravasation, a medical emergency requiring immediate intervention to prevent tissue damage. Nausea and vomiting (B) and oral burning (C) are less urgent side effects. Sitting with visitors (D) is a normal activity and not concerning.
The nurse is planning a staff education program about conflict resolution strategies. It is appropriate for the nurse to identify that compromising in a conflict may result in
- A. incomplete satisfaction of both parties’ concerns.
- B. appeasing an individual by self-sacrificing.
- C. suppression of thoughts and feelings.
- D. satisfaction of an individual’s interest regardless of the impact on others.
Correct Answer: A
Rationale: Compromising in conflict (A) often results in incomplete satisfaction for both parties, as each gives up something to reach agreement. Appeasing (B) involves self-sacrifice, suppression (C) avoids conflict, and individual satisfaction (D) reflects winning, not compromising.
The nurse notices an unlicensed assistive personnel (UAP) passing by several call lights during the shift. Which initial action should the nurse take?
- A. Approach the UAP about the behavior.
- B. Report unsafe behavior to the charge nurse.
- C. File an incident report due to safety risk.
- D. Ask another UAP to help cover this UAP's patient load.
Correct Answer: B
Rationale: Approaching the UAP (B) initially allows for clarification and correction of the nurse can address the behavior, promoting teamwork and addressing potential safety issues.. Reporting to the charge nurse (A) or filing an incident report (C) escalates prematurely. Assigning another UAP (D) does not address the root cause.