Nokea
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.
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Which of the following are components of the definition of critical thinking? Select all that apply.
- A. Reasoned thinking
- B. Openness to alternatives
- C. Adherence to established guidelines
- D. Ability to reflect
- E. Loyalty to traditional approaches
- F. Desire to seek the truth
Correct Answer: A, B, D, F
Rationale: Critical thinking includes reasoned thinking (A), openness to alternatives (B), reflection (D), and seeking truth (F). Adherence to guidelines (C) and loyalty to tradition (E) limit the flexibility required for critical thinking.
The nurse is triaging phone calls at a clinic for a group of clients. Which client situation requires immediate notification to the primary healthcare provider (PHCP)? A client who
- A. reports a strong metallic-like taste while taking newly prescribed metronidazole.
- B. reports a localized rash after starting prescribed sulfamethoxazole-trimethoprim.
- C. takes prescribed lithium and reports blurred vision.
- D. feels restless and reports difficulty sleeping while taking prescribed prednisone.
Correct Answer: C
Rationale: Blurred vision in a client taking lithium (C) suggests potential lithium toxicity, a medical emergency requiring immediate provider notification. Metallic taste with metronidazole (A) is a common side effect, rash with sulfamethoxazole-trimethoprim (B) needs monitoring but is less urgent, and restlessness with prednisone (D) is a known side effect.
The nurse is caring for a client recovering from hip surgery who needs to regain strength to climb the flight of stairs leading to their bedroom at home. The nurse should recommend a referral to a
- A. physical therapist (PT).
- B. nutritionist.
- C. C. case manager.
- D. D. occupational therapist (OT).
Correct Answer: A
Rationale: A physical therapist (A) specializes in improving strength and mobility, essential for stair climbing post-hip surgery. Nutritionists (B) focus on diet, case managers (C) coordinate care, and occupational therapists (D) address daily living activities.
The emergency department (ED) nurse is caring for a client with suspected bacterial meningitis. The nurse should take which priority action?
- A. Notify public health services
- B. Dim the lights in the assigned room
- C. Obtain blood cultures
- D. Explore the client's feelings regarding the diagnosis
Correct Answer: C
Rationale: Obtaining blood cultures (C) is the priority action for suspected bacterial meningitis to confirm the diagnosis and guide antibiotic therapy. While droplet precautions (not listed) are also critical to prevent spread, cultures are the most urgent among the options. Notifying public health (A) is secondary, dimming lights (B) addresses comfort, and exploring feelings (D) is not a priority in an acute infection.
The emergency department (ED) nurse is caring for a client who is 38 weeks pregnant and experiencing frequent contractions. The nurse observes a presenting part of the fetus during the exam. Which priority action should the nurse take?
- A. Assess the client's previous obstetric history
- B. Prepare for the delivery of the newborn
- C. Transport the client to the labor and delivery unit
- D. Time the frequency and duration of contractions
Correct Answer: B
Rationale: A visible presenting part (B) indicates imminent delivery, requiring immediate preparation for newborn delivery in the ED. Assessing history (A), transporting to labor and delivery (C), or timing contractions (D) delays critical action for an emergency birth.