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The nurse is caring for a client with congestive heart failure. Using the ISBAR format, Select the text that expresses the nurses' recommendation to the physician.
- A. Client reported a cough and shortness of breath while resting.
- B. The onset of symptoms was sudden and not relieved, with the client being positioned with the head of the bed at 90 degrees.
- C. Vital signs were obtained: 156/98; P 108; RR 26/minute; Oxygen saturation 91% on room air.
- D. Lung sounds had crackles in all fields.
- E. A rapid response was called because of the unstable vital signs.
- F. Dr. Thomas Smith was notified to obtain diuretics and critical care monitoring orders.
Correct Answer: B,F
Rationale: Notifying Dr. Smith for diuretics and critical care monitoring (F) is the recommendation in the ISBAR format, proposing specific actions for the physician to address the client’s worsening heart failure. Other options provide situation (A, B), background (C, D), or assessment (E) details.
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A patient in the prenatal clinic has stated her intention to choose formula feeding for her infant. Identify which action by the nurse is most appropriate in being a patient advocate.
- A. Remind the patient of why breast feeding is the best method of infant feeding.
- B. Request a referral to the lactation consultant.
- C. Determine the patient's knowledge base related to infant feeding options.
- D. Accept the patient's decision without further discussion.
Correct Answer: C
Rationale: Determining the patient’s knowledge base (C) respects her autonomy while ensuring informed decision-making, aligning with patient advocacy. Reminding about breastfeeding (A) or referring to a consultant (B) may pressure the patient, and accepting without discussion (D) neglects education.
The nurse in the emergency department (ED) is caring for a client experiencing septic shock. The nurse should prioritize
- A. obtaining an order to insert an indwelling urethral catheter.
- B. monitoring the client's serum white blood cell count and lactic acid.
- C. establishing frequent blood pressure monitoring.
- D. monitoring the client's capillary blood glucose.
Correct Answer: C
Rationale: Frequent BP monitoring (C) is the priority in septic shock to assess hemodynamic stability and guide fluid/vasopressor therapy, per Surviving Sepsis guidelines. Catheter insertion (A), lab monitoring (B), and glucose checks (D) are secondary to immediate circulatory assessment.
The nurse is caring for a client taking prescribed captopril. Which abnormal laboratory value should the nurse prioritize when notifying the healthcare provider?
- A. Serum creatinine 1.3 mg/dL (114.92 μmol/L) [Male: 0.6-1.2 mg/dL, Female: 0.5-1.1 mg/dL, Male 49-93 μmol/L, Female 22-75 μmol/L]
- B. Serum potassium 5.2 mEq/L (mmol/L) [3.5-5 mEq/L (mmol/L)]
- C. Serum phosphorus 4.6 (1.48 mmol/L) [2.5-4.5 mg/dL, 0.81-1.58 mmol/L]
- D. Blood glucose 135 mg/dL (7.5 mmol/L) [70-110 mg/dL, 4-6 mmol/L]
Correct Answer: B
Rationale: Hyperkalemia (potassium 5.2 mEq/L, B) is a priority with captopril, an ACE inhibitor, as it can cause life-threatening arrhythmias. Creatinine (A) and phosphorus (C) are slightly elevated but less urgent. Glucose (D) is elevated but not critical in this context.
A registered nurse (RN) and a licensed practical/vocational nurse (LPN/VN) are caring for a client who is violent and self-discontinued their peripheral vascular access. After initiating physical wrist restraints, which of the following tasks may the RN delegate to the LPN?
- A. Collect data on the client's skin integrity.
- B. Educate the client on the need for restraints.
- C. Initiate peripheral vascular access.
- D. Continually assess the client to determine if restraint use is necessary.
Correct Answer: A
Rationale: Collecting data on skin integrity (A) is within the LPN’s scope for monitoring restraint effects. Education (B) and ongoing restraint necessity assessment (D) require RN judgment, and initiating vascular access (C) may be outside LPN scope depending on state regulations.
The nurse is caring for a patient recovering from a client who has had cardiac catheterization via the right femoral artery. The nurse notes stable vital signs one hour post-procedure but cannot palpate the right pedal pulse. Which action would be the nurse's highest priority action?
- A. Assess bilateral lower extremity capillary refill
- B. Notify the severity physician
- C. Place bed in the Trendelenburg position
- D. Recheck pedal pulse with doppler
Correct Answer: B
Rationale: Absence of a pedal pulse post-catheterization (B) suggests vascular occlusion, requiring urgent physician notification to prevent limb ischemia. Checking capillary refill (A) or using Doppler (D) is secondary. Trendelenburg (C) is inappropriate for this issue.