Nokea
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.
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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 is caring for assigned clients. The nurse should initially follow up on the client who
- A. has a basilar skull fracture and has bruises under their eyes.
- B. had a craniotomy and has a change in the Glasgow coma scale (GCS) from 13 to 11 in the last hour.
- C. has amyotrophic lateral sclerosis (ALS) and is requesting to have resuscitation efforts withheld.
- D. has Guillain-Barré syndrome (GBS) and is reporting lower extremity muscle weakness.
Correct Answer: B
Rationale: A GCS drop from 13 to 11 post-craniotomy (B) indicates neurological deterioration, possibly from hematoma, requiring immediate follow-up. Bruises with skull fracture (A), ALS DNR request (C), and GBS weakness (D) are less urgent, though GBS needs monitoring.
The nurse is caring for assigned clients in the mental health unit. The nurse should initially follow up on the client who
- A. is admitted for psychosis and is pacing in the hallway, mumbling to themselves.
- B. is being treated for obsessive compulsive disorder and has increased the number of times they wash their hands.
- C. has a substance use disorder and refuses to attend group therapy for the second time.
- D. is diagnosed with borderline personality disorder and is insisting on seeing the charge nurse for an allegation of abuse two days ago.
Correct Answer: A
Rationale: Pacing and mumbling in psychosis (A) suggest agitation or worsening symptoms, posing a safety risk requiring immediate follow-up. Increased hand washing (B), therapy refusal (C), and abuse allegations (D) are less urgent, as they are chronic or procedural.
The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who
- A. had an adrenalectomy 24 hours ago and has become restless with the most recent blood pressure (BP) of 98/60 mm Hg.
- B. has a continuous infusion of heparin for the treatment of a pulmonary embolism (PE) and has an activated partial thromboplastin time (aPTT) of 70 seconds (normal 30-40 seconds).
- C. is receiving mechanical ventilation to treat hospital-acquired pneumonia (HAP) and was last suctioned via the endotracheal (ET) tube two hours ago.
- D. has a newly placed chest tube for hemothorax and has had 45 mL of bright red drainage in the past hour.
Correct Answer: A
Rationale: Restlessness and BP of 98/60 mm Hg 24 hours post-adrenalectomy (A) suggest possible adrenal crisis or hypovolemia, a life-threatening emergency requiring immediate follow-up. Elevated aPTT on heparin (B) indicates therapeutic anticoagulation, recent suctioning (C) is routine, and 45 mL chest tube drainage (D) is within normal limits, all less urgent.
The nurse in the emergency department is triaging a group of clients. It would be a priority for the nurse to follow up with the child
- A. reporting increased urinary frequency and pain during urination.
- B. diagnosed with leukemia who has petechiae on their torso.
- C. diagnosed with acute epiglottitis two days ago and is drooling.
- D. with otitis media who has a temperature of 101.1°F (38.4°C) and is crying.
Correct Answer: C
Rationale: Drooling in a child with acute epiglottitis (C) suggests airway obstruction, a life-threatening emergency requiring immediate follow-up. Urinary symptoms (A), petechiae in leukemia (B), and otitis media (D) are less urgent, though concerning.