Nokea
The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings requires immediate follow-up?
- A. Incisional pain rated 6 on a scale of 0 (no pain) to 10 (severe pain)
- B. Oral temperature of 99.5°F (37.5°C)
- C. Heart rate of 112 beats-per-minute (BPM)
- D. Hypoactive bowel sounds in all four quadrants
Correct Answer: C
Rationale: Tachycardia (112 BPM) at six hours post-operative (C) suggests possible complications like bleeding or infection, requiring immediate follow-up. Pain rated 6 (A) is expected, mild fever (B) is normal, and hypoactive bowel sounds (D) are typical post-surgery.
You may also like to solve these questions
The nurse has been tasked with developing and leading a multidisciplinary team to improve client safety and has been informed that previous group formations were unsuccessful due to poor team dynamics. When developing and leading this committee, it is essential that the nurse initially
- A. develop a code of conduct for the team.
- B. review how the team will be evaluated.
- C. review the goals for the team.
- D. establish deadlines for the team.
Correct Answer: C
Rationale: Reviewing team goals (C) initially aligns members toward a common purpose, addressing poor dynamics by fostering collaboration. A code of conduct (A), evaluation methods (B), and deadlines (D) are important but secondary to establishing shared objectives.
During a disaster triage situation with limited ICU beds and resources, the nurse must recommend which clients should receive priority for ICU admission. Which of the following clients should be prioritized? Select all that apply.
- A. A client with a flail chest and respiratory distress requiring intubation
- B. A client with a Glasgow Coma Scale (GCS) score of 3 and fixed pupils
- C. A client with septic shock responding to vasopressors and fluids
- D. A client with extensive full-thickness burns over 85% of the total body surface area
- E. A client with an open leg fracture and stable vital signs
- F. A client with a traumatic brain injury and signs of increasing intracranial pressure
Correct Answer: A, C, F
Rationale: Clients with flail chest requiring intubation (A), septic shock responding to treatment (C), and traumatic brain injury with increasing intracranial pressure (F) have salvageable conditions needing ICU care. GCS of 3 with fixed pupils (B) indicates poor prognosis, extensive burns (D) have low survival likelihood, and stable leg fracture (E) is non-critical.
The nurse is caring for assigned clients. The nurse should initially
- A. evaluate a client’s Mantoux test for tuberculosis tuberculin skin (TB) test for reactivity 48 hours after it has been administered.
- B. assess a client with atrial fibrillation who has an irregular pulse (P) of 90 beats/minute.
- C. apply the catheter prescribed medication to the lumbar back region of a client with chronic pain.
- D. administer the prescribed antibiotic scheduled for a client with peritonitis.
Correct Answer: D
Rationale: Administering antibiotics for peritonitis (C) is the priority to treat life-threatening intra-abdominal infection. TB test evaluation (D), AF pulse assessment (B), and lidocaine patch application (A) are less urgent, as they address stable or chronic conditions.
The nurse administers intravenous levofloxacin instead of the prescribed azithromycin. Which of the following actions should the nurse take first?
- A. Stop the infusion
- B. Complete an incident report
- C. Obtain vital signs
- D. Notify the primary healthcare provider (PHCP)
Correct Answer: A
Rationale: Stopping the infusion (A) is the first action to prevent further harm from the medication error. Notifying the provider (D), obtaining vital signs (C), and completing an incident report (B) follow after halting the incorrect medication.
During a busy shift, the nurse appropriately delegates tasks to the unlicensed assistive personnel (UAP). Which of the following is the nurse's primary responsibility?
- A. Document the completion of the task.
- B. Make a list of tasks not yet completed to pass on to the next shift.
- C. Observe the UAP for the duration of the task.
- D. Follow-up with the UAP to ensure completion of the task and evaluate the outcome.
Correct Answer: D
Rationale: The nurse’s primary responsibility is to follow up with the UAP (D) to ensure tasks are completed correctly and evaluate outcomes, maintaining accountability for delegated care. Documentation (A), listing incomplete tasks (B), and continuous observation (C) are not primary responsibilities.