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The nurse is caring for assigned clients. The nurse should initially assess the client who has
- A. left pulmonary empyema, a temperature of 102.4°F (39.1°C), and a pulse of 104.
- B. gentle bubbling in the water seal chamber of their chest tube when exhaling.
- C. a right pleural effusion and has decreased tactile fremitus in the right lobe.
- D. pneumonia and has a pulse oximetry of 90% while on 4 liters of nasal cannula oxygen.
Correct Answer: A
Rationale: Fever (102.4°F) and tachycardia (104) in empyema (A) suggest worsening infection or sepsis, requiring immediate assessment. Chest tube bubbling (B) is normal, pleural effusion findings (C) are expected, and 90% saturation (D) is stable with oxygen.
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The nurse is assisting the risk manager in reviewing a serious medication error. Which process should the nurse recommend be used to identify the origin of the issue and potential solution?
- A. Root cause analysis
- B. Collective bargaining
- C. Six Sigma
- D. Team STEPPS program
Correct Answer: A
Rationale: Root cause analysis (A) is the standard process to identify the origin of a medication error and develop solutions by analyzing contributing factors. Collective bargaining (B) is labor-related, Six Sigma (C) is a quality methodology, and Team STEPPS (D) focuses on teamwork, none specific to error investigation.
Client One, prednisone 10 mg PO Daily for asthma exacerbation
Client Two, acetaminophen 500 mg PO x 1 dose for fever
Client Three, magnesium oxide 250 mg PO Daily For chronic dode 150 mg PO Daily
Client Four, glargine insulin 15 units SubQ Daily for diabetes mellitus
The nurse is performing medication administration for four clients. Which client and medication should be administered first?
- A. Client One
- B. Client Two
- C. Client Three
- D. Client Four
Correct Answer: B
Rationale: Acetaminophen for fever (B) is the priority to address an acute symptom that may indicate infection or discomfort, requiring timely intervention. Prednisone (A), magnesium oxide (C), and glargine insulin (D) are daily medications with less immediate urgency.
The nurse triages phone calls for the primary healthcare provider (PHCP). Which client report requires immediate follow-up? A client reporting
- A. bilateral flank pain who has two nephrostomy tubes.
- B. abdominal cramping while instilling dialysate for peritoneal dialysis (PD).
- C. facial edema while being treated for nephrotic syndrome.
- D. a localized rash following the administration of ciprofloxacin for cystitis.
Correct Answer: C
Rationale: Facial edema in nephrotic syndrome (C) suggests worsening hypoalbuminemia or fluid overload, a medical emergency requiring immediate follow-up. Flank pain (A), dialysis cramping (B), and rash (D) are less urgent, as they are expected or manageable.
The nurse is discussing management styles with a colleague. Which of the following nursing leadership and management-related statements is accurate?
- A. Nurse managers possess personal accountability for not only their specific acts but also acts of delegation and supervision.
- B. Nurses and nurse managers are accountable for supervising others, except for unlicensed assistive personnel (UAP).
- C. When delegated to the appropriate person, the delegating nurse is no longer responsible for ensuring the task is performed correctly.
- D. Managing care entails micromanagement of the unit's staff.
Correct Answer: A
Rationale: Nurse managers are accountable for their actions and delegated tasks, including supervision (A), per nursing standards. UAPs are included in supervision (B), delegators remain responsible (C), and micromanagement (D) is ineffective, not a management goal.
The nurse is caring for assigned clients in the behavioral health unit. The nurse should initially assess the client who
- A. has postpartum depression who appears unkempt and dejected.
- B. recently lost their family in an accident and currently states, 'I want to be with them.'
- C. has anorexia nervosa and demands that she get reweighed.
- D. refused their second dose of prescribed lithium because of a fine hand tremor.
Correct Answer: B
Rationale: The statement 'I want to be with them' (B) indicates suicidal ideation, requiring immediate assessment for safety. Postpartum depression (A), anorexia demands (C), and lithium refusal (D) are concerning but less urgent.