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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.
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The nurse is witnessing a client provide informed consent. The client is demonstrating which ethical principle?
- A. Autonomy
- B. Justice
- C. Paternalism
- D. Veracity
Correct Answer: A
Rationale: Informed consent demonstrates autonomy (A), allowing the client to make self-determined decisions, per ethical principles. Justice (B) ensures fairness, paternalism (C) involves decision-making for the client, and veracity (D) is truth-telling, none central to consent.
The nurse is caring for a client receiving nasal cannula oxygen and prescribed warfarin for venous thromboembolism (VTE) prevention. The unlicensed assistive personnel (UAP) informs the nurse that the client has a nose bleed. The nurse should initially
- A. have the unlicensed assistive personnel (UAP) apply petroleum water-soluble jelly to nares.
- B. review the most recent activated partial thromboplastin time (aPTT).
- C. assess the client for bruising and bleeding gums.
- D. obtain an order to humidify the oxygen.
Correct Answer: C
Rationale: Assessing for bruising and bleeding gums (C) evaluates the extent of bleeding risk on warfarin. Applying jelly (A) is inappropriate, reviewing aPTT (B) is secondary, and humidifying oxygen (D) is not urgent.
The medical-surgical nurse is assigned to the intensive care unit (ICU). The nurse accepts the hand-off reports and indicates they are not qualified to provide the necessary care. It would be appropriate for the medical-surgical nurse to take which action?
- A. Refuse to provide any client care
- B. Document the concern in the client's medical record
- C. Notify the primary healthcare provider (PHCP)
- D. Report the concerns to the nursing supervisor
Correct Answer: D
Rationale: Reporting concerns to the nursing supervisor (D) ensures safe staffing and reassignment, protecting clients and the nurse. Refusing care (A) is unprofessional, documenting in records (B) is inappropriate, and notifying the provider (C) is not the nurse’s role.
The nurse is caring for the following assigned clients. The nurse should initially follow-up with the client who
- A. thirty minutes overdue to be ambulated in the hallway.
- B. refusing to eat their meal following an injection of glargine insulin.
- C. scheduled for discharge in three hours and needs transportation.
- D. requesting diphenhydramine after starting an intravenous antibiotic.
Correct Answer: B
Rationale: Refusing to eat after glargine insulin (B) risks hypoglycemia, requiring immediate follow-up to ensure glucose stability. Overdue ambulation (A), discharge planning (C), and diphenhydramine request (D) are less urgent than preventing a metabolic emergency.
The nurse is caring for assigned clients. The nurse should initially follow-up on the client who
- A. has chronic back, neck, and shoulder pain and is crying.
- B. is being treated for pneumonia and reports a persistent cough with thick, yellow mucus.
- C. had a colostomy placed three hours ago and has an edematous stoma with scant bloody drainage.
- D. is being treated for diabetes insipidus, and the family member reports the client has developed confusion.
Correct Answer: D
Rationale: Confusion in diabetes insipidus (D) suggests electrolyte imbalance or dehydration, a critical issue requiring immediate follow-up. Chronic pain with crying (A), pneumonia cough (B), and post-colostomy stoma (C) are less urgent, as they are expected or stable.