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The nurse is caring for a group of clients. It is a priority to follow up on which client situation? A client
- A. admitted with an asthma exacerbation that is wheezing while receiving albuterol via nebulizer.
- B. admitted with pulmonary emphysema who puts on their nasal cannula oxygen before eating.
- C. with pneumonia is ambulating around the nursing unit while wearing a surgical mask.
- D. receiving oxygen via nonrebreather and has an oxygen saturation of 92%.
Correct Answer: D
Rationale: Oxygen saturation of 92% on a nonrebreather (D) indicates inadequate oxygenation, requiring immediate follow-up to adjust oxygen or assess for deterioration. Wheezing during albuterol (A), oxygen use before eating (B), and masked ambulation (C) are expected or less urgent.
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A nurse is delegating tasks to the unlicensed assistive personnel (UAP). Which task is most appropriate for the UAP to perform?
- A. Assisting a client with dysphagia during oral feedings.
- B. Documenting a client’s response to a medication administered for pain relief.
- C. Collecting a clean-catch urine sample from a client.
- D. Removing a client’s indwelling urinary catheter per the provider’s order.
Correct Answer: C
Rationale: Collecting a clean-catch urine sample (C) is a non-invasive task within the UAP’s scope. Feeding with dysphagia (A), documenting medication response (B), and catheter removal (D) require clinical judgment or training beyond UAP scope.
The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply.
- A. At the start of the interview, inquire about the client's preferred pronoun.'
- B. Utilize binary gender terms on healthcare documentation.'
- C. Transgender individuals feel a variance between gender and natal sex.'
- D. Clients who are transgender may be reluctant to seek healthcare.'
- E. Inquire about any current or future plans for hormone therapy.'
Correct Answer: A, C, D, E
Rationale: Inquiring about pronouns (A), recognizing gender variance (C), acknowledging healthcare reluctance (D), and discussing hormone therapy (E) are inclusive and relevant. Binary gender terms (B) are inappropriate, as they exclude non-binary identities.
The emergency department (ED) nurse is caring for an infant who is choking on a foreign object. On assessment, the infant is conscious and not making any noises. The nurse should immediately
- A. begin chest compressions at 100-120/minute.
- B. attempt a blind finger sweep in the mouth.
- C. perform abdominal thrusts.
- D. give five back blows and five chest thrusts.
Correct Answer: D
Rationale: For a conscious choking infant, five back blows followed by five chest thrusts (D) is the standard intervention to dislodge the foreign object, per pediatric advanced life support guidelines. Chest compressions (A) are for unresponsive infants, blind finger sweeps (B) risk pushing the object deeper, and abdominal thrusts (C) are not used in infants due to injury risk.
The nurse is planning a staff education program about conflict resolution strategies. Which of the following would be an effective strategy in conflict resolution?
- A. Attempt to compare the person or situation to other people and situations.'
- B. Avoiding the conflict may ease frustration for those involved.'
- C. The goal of conflict resolution is to create a win-win situation for all.'
- D. Passively listen as individuals express themselves.'
Correct Answer: C
Rationale: Aiming for a win-win situation (C) is an effective conflict resolution strategy, promoting mutual benefit and collaboration. Comparing situations (A) is unhelpful, avoidance (B) delays resolution, and passive listening (D) lacks active engagement.
The nurse is caring for the following assigned clients. The nurse should immediately follow up with the client who has
- A. mechanical ventilation and the low-pressure alarm sounds.
- B. a new colostomy with refusal to participate in care.
- C. acute glomerulonephritis and has periorbital edema.
- D. atrial fibrillation with an irregular pulse.
Correct Answer: A
Rationale: A low-pressure ventilator alarm (D) suggests a leak or disconnection, risking airway compromise, requiring immediate follow-up. Colostomy refusal (A), periorbital edema (B), and irregular pulse in AF (C) are less urgent, as they are chronic or stable.