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The nurse is caring for the following assigned clients. It would be a priority to follow up with a client who
- A. is being treated for acute glomerulonephritis (AGN) and has periorbital edema.
- B. has urolithiasis and reports persistent nausea.
- C. is receiving continuous bladder irrigation and reports the need to void.
- D. just returned from a hemodialysis session and reports dizziness.
Correct Answer: D
Rationale: Dizziness post-hemodialysis (D) suggests hypotension or fluid shifts, a life-threatening complication requiring immediate follow-up. Edema in AGN (A), nausea with urolithiasis (B), and voiding sensation with irrigation (C) are less urgent.
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The nurse is triaging clients in the emergency department (ED). Which client should the nurse triage as emergent? A client
- A. reporting pleuritic chest pain with a productive cough.
- B. who is pregnant and reporting intermittent nausea and vomiting.
- C. who has an isolated area of reddened vesicles and malaise.
- D. with sudden onset of ataxia and dysarthria.
Correct Answer: D
Rationale: Sudden ataxia and dysarthria (D) suggest a stroke, an emergent condition requiring immediate triage for time-sensitive intervention. Pleuritic cough (A), pregnancy nausea (B), and vesicles/malaise (C) are less urgent.
The nurse is planning client care assignments. Which task should be delegated to the unlicensed assistive personnel (UAP)?
- A. The initial ambulation of a client following a laparoscopic hernia repair.
- B. Feed a client who has dysphagia.
- C. Applying sequential compression devices to a client’s lower extremities.
- D. Calling in prescriptions to the local pharmacy for a client ready for discharge.
Correct Answer: C
Rationale: Applying sequential compression devices (C) is a non-clinical task within the UAP’s scope. Initial ambulation (A), feeding with dysphagia (B), and calling prescriptions (D) require clinical judgment or RN/LPN skills due to risk or complexity.
The nurse is caring for a client with a platelet count of 18,000 mm3 [150,000-400,000 mm3]. What is the priority action the nurse should take?
- A. Review the client's most recent liver function tests.
- B. Educate the client to notify staff before getting out of bed.
- C. Obtain and monitor the client's temperature.
- D. Encourage the client to turn, cough, and deep breathe.
Correct Answer: B
Rationale: Severe thrombocytopenia (18,000 mm3) (B) risks bleeding, so educating the client to notify staff before moving prevents injury. Liver tests (A), temperature (C), and respiratory exercises (D) are secondary to immediate safety measures.
The nurse is providing handoff report to the oncoming nurse. Which information should be included? Select all that apply.
- A. As needed (PRN) medications that were administered
- B. Normal assessment findings for the shift
- C. Normal laboratory results
- D. Scheduled medications that were administered
- E. Abnormal vital signs
Correct Answer: A, D, E
Rationale: PRN medications (A), scheduled medications (D), and abnormal vital signs (E) are critical for care continuity, per ISBAR standards. Normal findings (B) and normal lab results (C) are less essential unless they impact care.
The nurse is providing a handoff report to a nurse in the critical care unit. The nurse states that it would be helpful for the primary healthcare provider (PHCP) to refer the client to a support group upon discharge. This statement represents which part of the ISBAR handoff report?
- A. Situation
- B. Background
- C. Assessment
- D. Recommendation
Correct Answer: D
Rationale: Suggesting a support group referral (D) is a recommendation, part of the ISBAR (Introduction, Situation, Background, Assessment, Recommendation) handoff, proposing actions for ongoing care. It is not situation (A), background (B), or assessment (C).