Nokea
The nurse is caring for a group of assigned clients. The nurse should immediately follow up on the client who
- A. has a closed-chest drainage system and has redness at the insertion site.
- B. is receiving treatment for ulcerative colitis and has had three bloody stools in the past hour.
- C. is being treated for a concussion and reports a headache rated as 4 on a scale of 0 (no pain) to 10 (severe pain).
- D. is being treated for an ischemic stroke and has a blood pressure of 100/58 mm Hg.
Correct Answer: D
Rationale: Hypotension (100/58 mm Hg) in ischemic stroke (D) suggests hemodynamic instability, risking cerebral perfusion and requiring immediate follow-up. Redness at chest tube site (A), bloody stools in ulcerative colitis (B), and mild headache in concussion (C) are concerning but less immediately life-threatening.
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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.
The nurse is planning a staff development conference about changing the process of how clients are seen at a clinic to a first come, first served basis. This proposed change will model which ethical principle?
- A. Nonmaleficence
- B. Veracity
- C. Paternalism
- D. Justice
Correct Answer: D
Rationale: A first-come, first-served process (D) models justice by ensuring fair and equitable access to care based on arrival time. Nonmaleficence (A), veracity (B), and paternalism (C) do not apply to this resource allocation change.
The home health nurse is assessing a client in their home with suspected carbon monoxide poisoning. The nurse should take which priority action?
- A. Move the client outdoors
- B. Notify the primary healthcare provider (PHCP)
- C. Auscultate the client's lung sounds
- D. Assess the client's pulse oximetry
Correct Answer: A
Rationale: Moving the client outdoors (A) is the priority to remove them from the carbon monoxide source, preventing further toxicity. Notifying the PHCP (B), auscultating lungs (C), and assessing oximetry (D) follow after ensuring safety, as oximetry may be falsely normal in CO poisoning.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with pericarditis who reports increasing chest pain while laying down flat.
- B. with cystic fibrosis who has a temperature of 102.5°F (39.2°C).
- C. who has rhinosinusitis and is reporting facial pain that increases when bending forward.
- D. who has hypertrophic cardiomyopathy and has dyspnea after ambulating in the hallway.
Correct Answer: A
Rationale: Increasing chest pain when lying flat in pericarditis (A) suggests worsening pericardial effusion, a life-threatening condition requiring immediate assessment. Fever in cystic fibrosis (B), sinusitis pain (C), and dyspnea in cardiomyopathy (D) are less urgent.
The nurse manager has observed a staff nurse return to work late multiple times following the lunch break. The nurse manager should take which initial action?
- A. Continue to observe the nurse's behavior
- B. Reprimand the nurse with written documentation
- C. Ask the nurse to check in before and after taking their lunch break
- D. Discuss with the nurse the consequences of being late
Correct Answer: C
Rationale: Asking the nurse to check in (C) is a proactive initial step to address tardiness while maintaining professionalism and gathering data. Continued observation (A) delays action, reprimand (B) is premature, and discussing consequences (D) escalates without initial intervention.