Nokea
The nurse is caring for a client with symptomatic sinus bradycardia. The nurse should recognizes that the priority action should is be to taken?
- A. review the client's most recent serum potassium level.
- B. document the findings.
- C. notify the severity rapid response team.
- D. continue monitoring the client's vital signs
- E. B
Correct Answer: C
Rationale: Symptomatic sinus bradycardia (B) requires immediate notification of the rapid response team (C) to address potential hemodynamic instability. Documenting (A), monitoring (B), or reviewing labs (D) delays critical intervention.
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The nurse is planning to interview a client interested in establishing care with a primary healthcare provider (PHCP). The nurse should initially
- A. obtain the client's vital signs.
- B. identify the client's chief complaint.
- C. provide a private area for the interview.
- D. inquire about the client's allergies.
Correct Answer: C
Rationale: Providing a private area (C) ensures confidentiality and comfort, the initial step for an interview. Chief complaint (B), allergies (D), and vital signs (A) follow after establishing privacy.
The Unlicensed Assistive Personnel (UAP) is helping a female patient with early ambulation postsurgery. The CNA has just applied a gait belt to the patient's waist. Which of the following actions by the CNA will need interference and correction by the supervising nurse?
- A. Holding onto the belt's outer edge or center, preventing the patient from leaning or drooping to one side.
- B. Pulling from the front of the belt, keeping forward momentum.
- C. Bringing the client to a nearby chair when she feels dizzy.
- D. Keeping the patient's body weight close to her own.
Correct Answer: B
Rationale: Pulling from the front of the gait belt (B) risks causing the client to lose balance or fall, requiring correction. Holding the belt (A), seating a dizzy client (C), and maintaining close body alignment (D) are appropriate and safe actions.
The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. is being treated for acute glomerulonephritis (AGN) and has periorbital edema.
- B. has urolithiasis and reports persistent nausea.
- C. is receiving continuous bladder irrigation and reports the need to void.
- D. just returned from a hemodialysis session and reports dizziness.
Correct Answer: D
Rationale: Dizziness post-hemodialysis (D) suggests hypotension or fluid shifts, a life-threatening complication requiring immediate follow-up. Edema in AGN (A), nausea with urolithiasis (B), and voiding sensation with irrigation (C) are less urgent.
The nurse is precepting a newly hired nurse on the medical-surgical unit. Which of the following actions, if performed first by the newly hired nurse, would demonstrate appropriate prioritization?
- A. Initiates a referral for a client needing home health care.
- B. Performs a central line dressing change on a client receiving 0.9% saline infusion.
- C. Collects a urine specimen from a client's indwelling urinary catheter.
- D. Obtains capillary blood glucose for a client receiving continuous regular insulin.
Correct Answer: D
Rationale: Obtaining blood glucose for a client on continuous insulin (D) is the priority to prevent hypo- or hyperglycemia, which can be life-threatening. Home health referral (A), dressing change (B), and urine collection (C) are important but less urgent, as they do not address immediate physiological risks.
The nurse is providing a handoff report to a nurse in the critical care unit. The nurse states that it would be helpful for the primary healthcare provider (PHCP) to refer the client to a support group upon discharge. This statement represents which part of the ISBAR handoff report?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: D
Rationale: Suggesting a support group referral (D) is a recommendation, part of the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) handoff, proposing actions for ongoing care. It is not situation (A), background (B), or assessment (C).