Nokea
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.
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During a disaster triage situation with limited ICU beds and resources, the nurse must recommend which clients should receive priority for ICU admission. Which of the following clients should be prioritized? Select all that apply.
- A. A client with a flail chest and respiratory distress requiring intubation
- B. A client with a Glasgow Coma Scale (GCS) score of 3 and fixed pupils
- C. A client with septic shock responding to vasopressors and fluids
- D. A client with extensive full-thickness burns over 85% of the total body surface area
- E. A client with an open leg fracture and stable vital signs
- F. A client with a traumatic brain injury and signs of increasing intracranial pressure
Correct Answer: A, C, F
Rationale: Clients with flail chest requiring intubation (A), septic shock responding to treatment (C), and traumatic brain injury with increasing intracranial pressure (F) have salvageable conditions needing ICU care. GCS of 3 with fixed pupils (B) indicates poor prognosis, extensive burns (D) have low survival likelihood, and stable leg fracture (E) is non-critical.
You are the charge nurse on a medical-surgical unit. You have noticed over the last several weeks that one of the nurses on your team is displaying anger and negative feelings, which is not at all characteristic of this experienced nurse. What is this nurse most likely experiencing?
- A. Burnout
- B. Role confusion and dissonance
- C. Ineffective role performance
- D. Fatigue
Correct Answer: A
Rationale: Persistent anger and negative feelings (A) in an experienced nurse suggest burnout, a state of emotional and physical exhaustion from prolonged stress. Role confusion (B), ineffective performance (C), and fatigue (D) may contribute but are less specific to the described emotional changes.
A nurse is working in a busy medical-surgical unit and has received report on the following four clients. The nurse should first see the client with
- A. A client who underwent surgery yesterday and is complaining of incisional pain at a level of 8/10
- B. new-onset atrial fibrillation who is complaining of chest pain.
- C. diabetes who has a foot wound that appears infected and an oral temperature of 100.4°F (38°C)
- D. advanced Alzheimer's disease who is confused and has had a recent fall.
Correct Answer: B
Rationale: New-onset atrial fibrillation with chest pain (B) suggests possible cardiac ischemia, a life-threatening emergency requiring immediate assessment. Severe pain (A), infected foot wound (C), and confusion post-fall (D) are urgent but less immediately life-threatening.
The nurse is triaging phone calls at a clinic. The nurse should initially follow-up with the client who reports
- A. decreased libido while receiving prescribed dutasteride.
- B. swelling in their right leg while receiving prescribed tamoxifen.
- C. hot flashes and night sweats while receiving prescribed letrozole.
- D. bone pain while receiving prescribed filgrastim.
Correct Answer: B
Rationale: Right leg swelling on tamoxifen (B) suggests deep vein thrombosis, a life-threatening emergency requiring immediate follow-up. Decreased libido (A), hot flashes (C), and bone pain (D) are expected side effects and less urgent.
The nurse has completed medication administration to assigned clients. The nurse should initially follow up on the client who received prescribed
- A. mirtazapine and reports sleepiness.
- B. citalopram and reports nausea.
- C. fluphenazine and reports fever.
- D. clonidine and reports dizziness while rolling over in bed.
Correct Answer: C
Rationale: Fever after fluphenazine (C) suggests neuroleptic malignant syndrome, a life-threatening emergency requiring immediate follow-up. Sleepiness with mirtazapine (A), nausea with citalopram (B), and dizziness with clonidine (D) are expected side effects and less urgent.