Nokea
The nurse is caring for a group of clients in the labor and delivery department. The nurse should prioritize assessing the client who
- A. is 39 weeks gestation with regular contractions every 3 minutes and reports perineal pressure.
- B. had an epidural placed 3 hours ago and reports a mild headache and has a distended bladder.
- C. delivered a term newborn 4 hours ago and has saturated one peri-pad since delivery and has a temperature of 99.6°F (37.6°C).
- D. is 37 weeks gestation with blood pressure 168/112 mmHg, reports a persistent headache.
Correct Answer: D
Rationale: Severe hypertension (168/112 mmHg) with headache at 37 weeks (D) suggests preeclampsia, a life-threatening emergency requiring immediate assessment to prevent seizures or organ damage. Perineal pressure (A), epidural headache (B), and postpartum findings (C) are less urgent.
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[Orders ]
olanzapine 2.5 mg by mouth daily
obtain daily weights
12-lead electrocardiogram
consult nutritional services
The nurse is reviewing the physician orders for a client admitted with anorexia nervosa reporting weakness and abdominal distention. The nurse should prioritize:
- A. administering olanzapine.
- B. consulting nutritional services.
- C. performing the 12-lead electrocardiogram.
- D. weighing the client.
Correct Answer: C
Rationale: The client with anorexia nervosa reporting abdominal distention and weakness is concerning for hypokalemia. The nurse should prioritize performing the 12-lead electrocardiogram because cardiovascular collapse may occur if the client's physical symptoms go unrecognized and untreated. Additional testing is required, including a complete metabolic panel and magnesium level. Features of hypokalemia on the electrocardiogram include U-wave development, ST depression, and shallow, flat, or inverted T wave.
The nurse has been made aware of the following client situations. The nurse should first assess the client
- A. who recently received tissue plasminogen activator (tPA) and has oozing at the insertion site of the peripheral vascular access device.
- B. who has acute kidney injury (AKI) and has voided 100 mL of urine in the past six hours.
- C. who has pericarditis and is sitting upright in the bed, leaning forward to help relieve the chest pain.
- D. has an intractable migraine headache and has vomited twice in the past two hours.
Correct Answer: A
Rationale: Oozing at the tPA insertion site (A) suggests bleeding risk, a critical complication due to thrombolytic therapy, requiring immediate assessment. Oliguria in AKI (B), pericarditis pain relief (C), and migraine with vomiting (D) are less urgent.
The nurse working in the emergency department is caring for a client with carbon monoxide poisoning. Which of the following would be the priority action to treat this condition?
- A. Initiate continuous pulse oximetry monitoring
- B. Administer high-flow oxygen
- C. Insert a peripheral vascular access device
- D. Obtain a 12-lead electrocardiogram (ECG)
Correct Answer: B
Rationale: High-flow oxygen (B) is the priority for carbon monoxide poisoning to displace CO from hemoglobin, per ACLS guidelines. Pulse oximetry (A) is unreliable in CO poisoning, IV access (C) and ECG (D) are secondary to oxygenation.
The nurse is caring for an infant who is experiencing a tetralogy of Fallot (tet) spell. The nurse should take which priority action?
- A. Obtain a prescription for propranolol
- B. Establish a peripheral vascular access device
- C. Calm the infant
- D. Notify the healthcare provider
Correct Answer: C
Rationale: Calming the infant (C) during a Tetralogy of Fallot spell reduces oxygen demand and improves oxygenation, the priority action to stop the hypercyanotic episode. Propranolol (A), vascular access (B), and provider notification (D) are secondary to immediate symptom management.
You are the charge nurse on a medical-surgical unit. You have noticed over the last several weeks that one of the nurses on your team is displaying anger and negative feelings, which is not at all characteristic of this experienced nurse. What is this nurse most likely experiencing?
- A. Burnout
- B. Role confusion and dissonance
- C. Ineffective role performance
- D. Fatigue
Correct Answer: A
Rationale: Persistent anger and negative feelings (A) in an experienced nurse suggest burnout, a state of emotional and physical exhaustion from prolonged stress. Role confusion (B), ineffective performance (C), and fatigue (D) may contribute but are less specific to the described emotional changes.